Drugs, AIDS, and Harm Reduction
HOW TO SLOW THE HIV EPIDEMIC
IN EASTERN EUROPE AND
THE FORMER SOVIET UNION Drugs, AIDS, and Harm Reduction
HOW TO SLOW THE HIV EPIDEMIC
IN EASTERN EUROPE AND
THE FORMER SOVIET UNION
IHRD International Harm Reduction Development
OPEN SOCIETY INSTITUTE © 2001 Open Society Institute
The International Harm Reduction Development (IHRD) program of the Open Society Institute supports local, national, and regional initiatives in Central and Eastern Europe, the Russian Federation, and Central Asia that address drug problems through innovative measures based on the philosophy of harm reduction. Harm reduction programs attempt to diminish the individual and social harms associated with drug use—especially the risk of HIV infection. Harm reduction encompasses a wide range of drug user services, including needle and syringe exchange, methadone treatment, health education, medical referrals, and support services.
For more information, contact: International Harm Reduction Development program Open Society Institute 400 West 59th Street New York, NY 10019 USA Tel: 212.548.0677 Fax: 212.428.4617 E-mail: [email protected] www.soros.org/harm-reduction
IHRD Kasia Malinowska-Sempruch, Director Sue Simon, Associate Director Anna Moshkova, Program Officer Jennifer Traska Gibson, Program Coordinator Matt Curtis, Program Coordinator Magdelena Sklarski, Training Coordinator
Drugs, AIDS, and Harm Reduction was produced by IHRD and OSI’s Communications Office with the editorial help of John Heller, Jennifer Lisle, Jeff Hoover, Rebecca Foster, and Daniel Wolfe.
Photography credits: © Jacqueline Mia Foster: front and back covers, pages 24, 32-33. © John Ranard: pages 4-5, 7, 8-9, 10, 13, 16-17, 18-19, 21, 28, 70-71.
Design: Jeanne Criscola/Criscola Design Printing: Herlin Press, Inc. CONTENTS
6 FOREWORD: REDUCING HARM IS A REALISTIC GOAL by Kasia Malinowska-Sempruch
8 DRUGS, AIDS, AND HARM REDUCTION
10 I. THE CRISIS: RISING DRUG USE AND HIV IN EASTERN EUROPE
18 II. THE BETTER ALTERNATIVE: HARM REDUCTION PROGRAMS
24 III. OSI’S LEADERSHIP IN THE HARM REDUCTION MOVEMENT
30 AFTERWORD: HARM REDUCTION PROGRAMS EXEMPLIFY OPEN SOCIETY VALUES by Aryeh Neier
32 DIRECTORY: HARM REDUCTION PROGRAMS IN EASTERN EUROPE AND THE FORMER SOVIET UNION
72 NOTES
Traditional, authoritarian methods of drug control do not stem the tide of drug use or the social and health harms associated with it. By contrast, harm reduction methods work. FOREWORD: REDUCING HARM IS A REALISTIC GOAL
As many as four million people in Eastern Europe and the former Soviet Union are injecting drug users at great risk of becoming infected with HIV from shared injection equipment. We know that traditional, authoritarian methods of drug control do not stem the tide of drug use or the social and health harms associated with it. By contrast, harm reduction methods work. Harm reduction, a nonjudgmental, humane public health response to drug use, is premised on the conviction that it is more productive to integrate drug users into society than to separate them. It also assumes that when drug users are provided the opportunity, they make lifestyle changes that improve their overall health. The realistic goal of reducing the harms caused by drug use replaces the unrealistic goal of eliminating drug use altogether. Harm reduction, practiced for many years in Western Europe, North America, and Australia, has proven effective. Harm reduction in Eastern Europe and the former Soviet Union, however, has met with opposition from people who see it as an alien Western methodology that inappropriately slipped through the borders that started opening in the late 1980s. By moving the philosophy and practice beyond its origins, the International Harm Reduction Development (IHRD) program and its partners have established that harm reduction can indeed be adapted to the needs of this particular region. IHRD, a program of the Open Society Institute, has supported harm reduction projects that are scrupulously designed to respond to the social and cultural realities of the populations they serve. The projects described in this publication reflect the heterogeneity of the region. The people who developed these projects to fit into the social and cultural landscapes are training others, reinforcing indigenous priorities. Local governments are beginning to take notice and to respect the validity of these activities. The practices of harm reduction are taking hold.
6 IHRD To slow the HIV epidemic, replication of these harm reduction projects must outpace the proliferation of HIV. This may still be possible since the epidemic is in its early stages, but it can only happen if communities, politicians, law enforcement, and all citizens recognize the gravity of the crisis and the urgency of responding. We are proud of the pilot projects OSI has funded. We hope that the good sense behind their activities, the effectiveness of their results, and the courage of the people who run them will inspire others in the region to replicate their efforts—quickly and comprehensively.
Kasia Malinowska-Sempruch Director International Harm Reduction Development program Open Society Institute
HIV-positive babies in a general hospital.
FOREWORD 7 DRUGS, AIDS, AND HARM REDUCTION
An HIV patient's bed in the hallway of a hospital.
Health care systems in the region remain in poor shape to cope with the twin epidemics of drug use and HIV infection.
8 IHRD The global HIV epidemic is spreading through the countries of Eastern Europe and the former Soviet Union in tandem with a steep rise in injection drug use. In parts of the region, the HIV infection rate is increasing faster than anywhere else in the world. Despite such alarming statistics, injecting drug users (IDUs), who are among the most at risk of HIV infection, are not receiving the attention and care they deserve—largely because prejudice against them hinders efforts to establish appropriate services and policies, such as harm reduction strategies, that could help prevent HIV infection. Experience in North America, Australia, Western Europe, and elsewhere shows that needle/syringe exchanges and other harm reduction approaches are effective not only in diminishing risks to IDUs but in curbing the HIV epidemic overall. The International Harm Reduction Development (IHRD) program of the Open Society Institute, in partnership with Soros foundations in Eastern Europe and the former Soviet Union, has supported 162 harm reduction programs at 128 organizations to provide drug users with access to clean needles/syringes, substitution drug therapies, sexual health education, and a variety of social care services. More support from governments and funders is desperately needed to sustain and expand these activities. Among other necessary developments, strong political leadership is critical to overcoming public resistance to helping homeless youth, sex workers, prisoners, and other often marginalized people who make up a disproportionately high number of IDUs. The urgency is to act quickly in Eastern Europe and the former Soviet Union before the HIV epidemic spreads further and thousands more begin to die.
THE CRISIS 9 I THE CRISIS: RISING DRUG USE AND HIV IN EASTERN EUROPE
The main factor exposing injecting drug users to the risk of HIV infection is the sharing of contaminated injection equipment.
10 IHRD STARK FIGURES: THE STEEPEST HIV CURVE IN THE WORLD Increasingly large numbers of people in Eastern Europe and the former Soviet Union are injecting illicit drugs. Estimates at the end of 2000 put the number between 2.3 million and 4 million IDUs in the region. In Russia alone, estimates range from 1 million to 2.5 million. The rise is particularly rapid in many urban areas. For example, out of 32,000 young people between 15 and 29 years of age in the Kazakh city of Temirtau, at least 3,000 are believed to be IDUs.1 HIV infection shadows injecting drug use. In 1995, the number of HIV infections in Eastern Europe and the former Soviet Union was estimated at below 30,000. At the end of 1999, the number for the region had climbed to 420,000, and the United Nations announced that the newly independent states had the steepest HIV infection curve in the world.2 A year later, at the end of 2000, the number of HIV infections in Eastern Europe and the former Soviet Union had almost doubled, to 700,000.3 Despite the UN’s warnings, however, few governments or international funders have moved to mobilize sufficient resources to respond to the disease in the region. Russia has been particularly hard hit by the epidemic. “In one year, more people have become infected with HIV in Russia than all previous years combined,” Peter Piot, executive director of UNAIDS, said in November 2000.4 At that time, UNAIDS put the number of HIV-positive people in Russia at 300,0005 by the end of 2000. Vadim Pokrovsky, head of Russia’s Center on AIDS Control and Prevention, believes the epidemic in his country is even more severe. In April 2001, he estimated that there were 500,000 HIV-positive people in Russia at the end of 2000 and that the number would rise to 1 million by the end of 2001.6 With a huge majority of the region’s HIV cases traceable to injecting drug use (80 percent of the cases in the newly independent states, for example), there is hope that bold measures will staunch the epidemic’s spread.7 But the window of opportunity to make a difference is closing. Unless comprehensive harm reduction programs are adopted throughout the region, more and more people who inject drugs will contract HIV. And, as the percentage of cases
THE CRISIS 11 resulting from sexual contact grows (often systems have moved in the other direction, placing transmitted unknowingly by IDUs), HIV responsibility for health care in the hands of consumers infection will spread throughout the and putting poor people and marginalized groups at great risk. population, increasing the number of people The consequences are disheartening for public who need treatment and services—and making health. Before 1989, for example, most Soviet-bloc the epidemic even more difficult to contain. countries paid obstetricians and gynecologists to visit remote areas once or twice each month to provide care for rural women. After 1989, most of these services UNEXPECTED CONSEQUENCES: were discontinued. Before 1989, the countries of TRANSITION’S EFFECT ON THE EPIDEMIC Eastern Europe and the former Soviet Union were Social and economic conditions in Eastern Europe and almost syphilis-free. Now Russia, Belarus, Ukraine, the former Soviet Union during the past decade— Kazakhstan, and Kyrgyzstan report overwhelming increasing poverty, high unemployment, labor increases in the number of syphilis cases. migration, inadequate health care, and a lack of Clearly, the coercive system of the previous regime preventive health education—provided fertile ground has no place in a democratic society. But neither does a for the rise in injecting drug use and facilitated the system that offers health care only to those with spread of HIV. resources while providing little or no help to those most The drug industry flourished after the collapse of in need. communism. Many people who were hard hit by unemployment and poverty turned to growing and selling drugs as a way to survive. Many more people HARMFUL BEHAVIOR: SHARING NEEDLES became consumers of drugs, seeking escape from Fearing contact with state agencies or the police, many hardship, disillusionment, and social dislocation. users of illegal drugs refuse to visit health care Millions of refugees, uprooted by numerous wars, also professionals even if they are eligible for care. As a contributed to the tidal wave of drug use. result, they lack knowledge about the health risks of The opening of borders allowed drugs to move injecting drug use in general, and their own health freely throughout the region. Afghanistan is the world’s situation in particular. In many countries, the largest producer of opium, responsible for 75 percent of deteriorating health care systems cannot provide the the global supply in 1999. From Afghanistan, narcotics public with even the most basic HIV prevention spread into the neighboring Central Asian countries information. (Tajikistan, Turkmenistan, and Uzbekistan) and then HIV infection can spread at extraordinary rates through nearby Armenia, Azerbaijan, Georgia, among injecting drug users. In Svetlogorsk, Belarus, for Kazakhstan, and Kyrgyzstan and all along drug example, HIV prevalence among IDUs rose to more than trafficking routes into the West. 55 percent within one year after the first HIV cases were And where the drugs traveled, HIV followed. reported.8 In some cities in Ukraine, overall rates of HIV Health care systems in the region remain in poor infection among injecting drug users rose from almost shape to cope with the concurrent epidemics of drug zero in 1994 to more than 50 percent two years later.9 use and HIV infection. Under communism, health care The main factor exposing IDUs to the risk of HIV services were coercive to the point of violating human infection is the sharing of contaminated injection rights. Today’s partially market-driven health care equipment.
12 IHRD Overcrowding, inadequate medical care, and rampant drug use in the region’s prisons facilitate the spread of many infections, including HIV.
The HIV ward in a prison hospital.
THE CRISIS 13 Unauthorized possession of needles and syringes is piercing, and tattooing. illegal in many countries of Eastern Europe and the The results are disastrous. In Ukraine, it is former Soviet Union. Lack of access to clean needles estimated that 7 percent of prisoners are infected with and syringes forces many users in the region to share HIV.14 About one-fifth of Latvia’s known HIV cases are injection equipment and puts them at risk of in prison, and half of the new cases reported annually contracting HIV. Blood to blood transmission spreads are coming out of the penitentiary system. Up to 87 HIV even more rapidly than unprotected sexual contact. percent of these new cases may be IDUs.15 In some Ukrainian cities, the rate of needle sharing has A criminal justice policy that forces nonviolent been estimated at upwards of 80 percent.10 Needle and IDUs into the closed environment of prison, where syringe sharing also exposes drug users to a range of HIV spreads quickly through sex and shared needles, other blood-borne diseases, including hepatitis C. amounts to a disastrous public health policy—inside and outside prison walls. “Governments and prison authorities have a moral BREEDING GROUNDS FOR DISEASE: and legal responsibility to prevent the spread of HIV OVERCROWDED, UNSANITARY PRISONS infection among prisoners and prison staff and to take Prison conditions in Eastern Europe and the former care of those infected,” says Cees Goos of the World Soviet Union facilitate the spread of many infections, Health Organization. “They also have a responsibility to including HIV. Substandard nutrition in prisons is prevent the spread of HIV among communities. typical, as is a lack of basic medications, essential Prisoners are the community. They come from the medical equipment, light, and ventilation. Most prisons community, they return to it. Protection of prisoners is are overcrowded and unsanitary. Occupation rates in protection of our communities.” Romania’s prisons, for instance, run from 150 percent to 700 percent, according to the General Directorate of Penitentiaries.11 In Russia, cells meant for 28 hold up to A DEADLY COMBINATION: HIV AND TB 110 people. Inmates often sleep in shifts.12 Overcrowded prisons are also a leading cause of the Overcrowding in the region’s prison systems is skyrocketing tuberculosis (TB) rate in Russia—up 80 largely due to overeager drug policies that mimic the percent since 1990. The Global Impact of Drug-Resistant U.S. “zero tolerance” approach to drug control. In the Tuberculosis, a 1999 report prepared by Harvard Medical last few years, Poland, Hungary, and the Czech School’s Program in Infectious Disease and Social Republic, for example, have passed legislation modeled Change and funded by OSI, documented that many of after this misguided and counterproductive U.S. the TB cases in Russia and Estonia involved multidrug- strategy. In Russia, which shares with the United States resistant tuberculosis (MDR-TB).16 the highest incarceration rate in the world, the number In Russia, according to a New York Times article in of people imprisoned for the non-medical use of drugs December 2000, health experts describe the prison has increased five-fold over the last three years. system as an “epidemiologic pump” pouring TB into the Drug use is rampant in the region’s prisons. A general population.17 Any type of infectious disease recent study by Medecins Sans Frontieres found that in makes a person more susceptible to a host of other seven Russian prisons 43 percent of the inmates had health problems. Deaths from infectious diseases are injected drugs and, of those, 13.5 percent started in many times higher in Russia than in most developed prison.13 In addition to sharing needles, other risky countries. behavior in prison includes forced or voluntary HIV and TB are closely linked. About 13 million unprotected sex between men, self-mutilation, people worldwide are infected with both HIV and the
14 IHRD germ that causes TB.18 Up to 50 percent of people living with Moscow’s Federal AIDS Institute found that 15 percent HIV can expect to develop TB, the most common cause of of the sex workers tested HIV positive. “Think about it— death in persons with HIV throughout the world. that is 15 percent of the 70,000 women who will be out “HIV severely weakens the immune system, and there tonight,” said Arkadiusz Majszyk, the UN official makes people highly vulnerable to diseases such as TB,” who produced the report. “Which means their clients get said Dr. Peter Piot, executive director of UNAIDS.19 it, and pass it on to their families, and back to other “According to our latest figures, nearly two-thirds of all prostitutes, and so on.”24 people with HIV or AIDS were living in the countries with the highest TB burden in the world. The link between the two is inescapable.” VULNERABLE POPULATIONS: “Effectively treating TB will not solve the SPECIAL NEEDS OF THE ROMA worldwide AIDS crisis,” Piot said, “but it will The Roma are the most vulnerable population significantly reduce its burden.” throughout Central and Eastern Europe. As a group, they are subject to the worst conditions—slum-like housing, chronic unemployment, poor health care, lack BRINGING HIV HOME: SEX WORKERS AND of access to public services, and inferior, segregated THEIR CLIENTS schools. Discrimination plays a significant role in The number of people working in the sex industry in marginalizing the Roma; non-Roma often use them as Eastern Europe increased dramatically during the convenient scapegoats for difficult problems that affect 1990s—for many women, sex work is their only means the entire society. As a result, injecting drug use and of survival. Sex workers who inject drugs and share HIV risk behavior are controversial issues for the contaminated injection equipment are at a high risk of Romani community and its leaders. contracting HIV. Sexual contact with clients, often However, given their poverty and lack of access unprotected at the clients’ demand, increases the to services, it is indisputable that many Roma are chances of HIV infection spreading more widely. at risk of drug use and HIV infection. Illiteracy, It is estimated that between 25 to 35 percent of sex discrimination, and cultural distance further increase workers in the Russian cities of Moscow and Volgograd, the risk. Reliable figures are difficult to obtain, but the Belarus capital of Minsk, and the Ukrainian cities of researchers report a rise in injecting drug use within Odessa and Donetsk inject drugs.20 HIV prevalence Romani communities.25 among sex workers has reached an estimated 15 percent Many Roma are uninformed about the risks in some of these cities. In Kaliningrad, Russia, associated with needle sharing and unprotected sex— anywhere from 40 to 80 percent of the sex workers are a situation that will remain unchanged as long as thought to be HIV positive.21 countries lack culturally competent education and Sexual transmission of HIV is growing in areas of prevention services for Romani communities. In the Russia and Ukraine where the drug use and HIV Czech Republic, Slovakia, and Hungary, for example, epidemics have existed for a number of years. In primary drug prevention and safer sex projects are Kaliningrad and Odessa, sexual transmission has gone aimed at the majority population and seldom reach up from an estimated 5-15 percent of newly detected Romani youngsters. HIV testing, drug treatment, and case in 1996 to 30-35 percent in 2000.22 harm reduction programs rarely take into consideration Moscow is particularly vulnerable since it has the Romani cultural attitudes toward, for example, explicit region’s largest sex worker population, with estimates of sex education, or their general distrust of government up to 70,000 sex workers.23 A study in the fall of 2000 by institutions.
THE CRISIS 15 THE WRONG APPROACH: PUNISHING programs. The police in some countries round up young THE DRUG USER people suspected of drug use to search for needle marks Many countries in Eastern Europe and the former (known as “tracks”) or force them to be tested for HIV. Soviet Union attempt to control injecting drug use Those who test positive have their drug use and HIV through harsh, inappropriate measures. A few years status officially registered with the police. ago, for example, the Russian Duma (parliament) These measures not only have failed to reduce passed a law making it illegal to be an addict, thus drug-related harm but have forced IDUs further jeopardizing participation in all drug treatment underground, encouraging needle sharing and other
Harsh, inappropriate laws and police practices have forced injecting drug users further underground, encouraging needle sharing and other risky behaviors.
Police interrogate a student who bought a small amount of marijuana.
16 IHRD risky behaviors. In response to police searches for track so inadequate as to be worse than no treatment at all. marks, for example, users have begun injecting into Many countries force IDUs into locked wards, drugging their necks, groins, and underarms—parts of the body them with tranquilizers to keep them sedated but where the marks are less evident. Injecting into these offering no help with painful withdrawal symptoms. areas, however, increases the risk of hitting an artery Counseling, peer support, and other approaches that and/or incurring severe nerve damage. recognize the human needs and psychological The punitive approach has extended to official drug struggles of breaking free of addiction are rarely used treatment programs, which are few in number and often in the region.
THE CRISIS 17 II THE BETTER ALTERNATIVE: HARM REDUCTION PROGRAMS
The Medecins du Monde needle exchange bus in St. Petersburg.
Needle/syringe exchange programs decrease needle sharing, reduce HIV prevalence, and do not lead to higher rates of illegal drug use or injecting.
18 IHRD “The basic principles of harm reduction begin with the understanding that drugs are here to stay. There will never be a drug-free society, and in fact there has never been a drug-free society in civilized human history. Our challenge is not how to eliminate drugs from our midst . . . [but] to learn to live with drugs in such a way that they cause the least possible harm.” ETHAN NADELMANN, EXECUTIVE DIRECTOR, LINDESMITH CENTER-DRUG POLICY FOUNDATION
IHRD-supported programs seek to provide drug users with a range of effective alternative interventions based on the philosophy of harm reduction. Unlike many drug treatment approaches, harm reduction does not demand complete abstinence from drug users as a precondition for service delivery, recognizing that active injectors can take steps to protect themselves from drug-related harms. Harm reduction practitioners believe that positive changes in behavior are more likely to result when drug users are met with supportive care rather than violence and incarceration. Harm reduction does not deny the value of helping people become drug free or the benefits of abstinence. But since these goals may be longer term and perhaps, for some, unattainable, services to reduce risks in the interim—particularly the risk of HIV infection— are essential to avert personal and public health disasters.26 Within a harm reduction perspective, all positive behavioral change—such as disinfecting needles between injections and using clean injecting equipment—is regarded as meaningful progress. Though they may seem like minor steps in addressing the over- arching societal effects of drug use, such changes have had powerful and widespread public health benefits, particularly in reducing HIV transmission. Just as importantly, perhaps, they convey an intangible symbolic message to drug users, reassuring them that they are vital members of the general community whose well-being is treasured. In practice, harm reduction programs frequently include needle/syringe exchange and substitution therapies such as methadone treatment programs. These programs are often complemented by other support services, including educational outreach, counseling, overdose prevention efforts, teaching of safer injecting techniques, basic medical treatment and referrals, and
THE BETTER ALTERNATIVE 19 testing for HIV, TB, hepatitis, and sexually referrals to social workers, advocates, doctors, and transmitted diseases (STDs) such as syphilis detoxification programs. and gonorrhea. Needle/syringe exchange programs often rely on current or former drug users to serve as outreach consultants, staff, or volunteers. Throughout the NEEDLE/SYRINGE EXCHANGES: region, needle/syringe exchanges are run both by HOW THEY WORK government agencies and NGOs.
“Needle exchange staff must often begin by convincing users that their lives are worth HOW DO WE KNOW SYRINGE/NEEDLE something. Users are surprised that anyone would EXCHANGE IS EFFECTIVE? take an interest in their lives and health. This can Numerous studies from around the world over the past be very powerful. Program staff, just by caring, can 15 years confirm that needle/syringe exchange help catalyze a will to live and change.” programs decrease needle sharing, reduce HIV KASIA MALINOWSKA-SEMPRUCH, IHRD DIRECTOR prevalence, and connect members of socially and economically marginalized groups with drug treatment At a minimum, needle/syringe exchange programs and other services.27 These studies also conclude that provide IDUs with clean injecting equipment in such programs do not lead to higher rates of illegal drug exchange for used equipment. This straightforward act use or injecting.28 has proven effective in decreasing needle sharing In the 1990s, researchers in the United States among users, getting dirty needles off the streets, and reported the results of a study on the effects of reducing the incidence of HIV. needle/syringe exchanges over a five-year period.29 Accessibility of Services. Needle/syringe exchange They found that such programs neither increased drug programs seek to be as accessible as possible to all who use among current IDUs nor “recruited” new injectors. may possibly benefit from them. Times, locations, and In fact, injection frequency among IDUs in the services are frequently designed around local drug use community decreased from 1.9 injections per day to patterns. Services are offered at stationary sites, where 0.7, and the percentage of new initiates into injecting users come to exchange injecting equipment, or drug use decreased from 3 percent to 1 percent. through mobile exchange units that travel on fixed A separate study of 81 cities around the world schedules to reach drug users where they congregate. In compared HIV infection rates among IDUs in cities that some instances, service providers and volunteers travel had needle/syringe exchange programs with those that on foot to exchange needles/syringes. did not. In the 52 cities without such programs for Bridge to Other Services. By providing easily IDUs, HIV infection rates increased by an average of 5.9 accessible services, staff and volunteers at percent a year. In the 29 cities with needle/syringe needle/syringe exchange programs establish trusting exchanges, HIV infection rates decreased by an average relationships with active injectors. These relationships of 5.8 percent a year.30 serve as a bridge between drug users and a range of From a purely financial perspective, providing potentially lifesaving services and information about injecting drug users with clean needles, condoms, and drug toxicity, safer sex, legal rights, and health. Many safer sex information is more cost effective than needle/syringe exchange programs offer basic medical treating a person with AIDS. It is, of course, also much care, free condoms, counseling, and noncoercive less costly for a society’s overall health and welfare.
20 IHRD Medecins Sans Frontieres (MSF) training session for Russian doctors and health care workers.
Providing injecting drug users with clean needles, condoms, and safer sex information is less costly for a society’s overall health and welfare than treating a person with AIDS.
THE BETTER ALTERNATIVE 21 SUBSTITUTION THERAPY PROGRAMS: countries, although a small number of them now HOW THEY WORK operate in the region, often with the support of local authorities. “Methadone maintenance insures that the drug user comes to a treatment institute regularly. When they’re here we can offer them tests for TB, HIV, and HOW DO WE KNOW METHADONE other medical services. If they have other health TREATMENT IS EFFECTIVE? problems, such as thrombosis or ulcers on their legs, The benefits of substitution therapy have been well we can treat them. This contact is substantial. established by hundreds of scientific studies. Their status changes from being illegal and Compared to other major drug treatment modalities— underground to being a part of society.” drug-free outpatient treatment, detoxification centers, EMILIS SUBATA, DIRECTOR, VILNIUS SUBSTANCE ABUSE and therapeutic communities—methadone is the most TREATMENT CENTER, VILNIUS, LITHUANIA rigorously studied option and has yielded the best results. Since it contributes to lowered frequencies of Substitution therapy is delivered through clinics that drug injection and needle sharing, methadone therapy dispense a daily dose of methadone or other synthetic is associated with a reduced risk of HIV, hepatitis, and narcotic medication to those with an opiate addiction. other blood-borne infections.31 It is also linked to It is used successfully in many regions of the world to decreases in crime since patients no longer need to reduce needle use, help connect drug users with turn to theft or other illegal activity as a means of ongoing monitoring and care, and enable them to break financing the purchase of illegal heroin or other their addiction so they can live healthier, more opiates.32 And finally, methadone is very cost effective— productive lives in the community. especially when compared with the high costs of Breaking Heroin Dependence. People who are incarceration. addicted to opiates such as heroin are physically dependent, and they experience severe craving and withdrawal symptoms if the amount of opiates in their HARM REDUCTION WORLDWIDE: GROWING bodies falls below a certain level. They continue to take SUPPORT AND PERSISTENT OPPOSITION heroin to keep this from happening. Methadone and other synthetic treatments, properly prescribed, can “A colleague of mine has remarked that the biggest help users stabilize and reduce or eliminate their risk factor for HIV is politicians. He’s right.” dependence on heroin by stopping the withdrawal and JEAN-PAUL GRUND, HARM REDUCTION EXPERT the cravings for opiates. Regular Clinic Visits. Methadone, the most Despite their demonstrated success at reducing drug- common substitution therapy in the region, is related harms, needle/syringe exchanges and dispensed in liquid form to clients who visit programs methadone programs have vocal opponents. Some on a regular schedule. Methadone clinics use this detractors argue that these programs endorse drug use regular contact with clients to share information on by not requiring abstinence. Others claim that offering drug use, health, and safer sex and to screen for HIV or clean needles encourages more casual drug users to other blood-borne diseases. Clinics also offer referrals become addicted or that substitution therapy fails to for medical treatment or social care. help because it replaces one dependency for another. Methadone and other substitution therapies are These views, often based on longstanding suspicion of illegal in many Eastern European and former Soviet and prejudice against drug users, persist despite
22 IHRD extensive evidence indicating that harm reduction Southern Europe already have experience with harm interventions promote public health, save money, do reduction approaches, although they remain not encourage drug use, and ultimately advance overall controversial. Authorities in countries such as Bulgaria, human rights. Poland, and the Czech Republic have tentatively In many countries, a wide gap exists between what accepted harm reduction programs. By contrast, the has been scientifically proven and what is politically concept of harm reduction is new and particularly feasible. Leading authorities in the United States, such sensitive in many of the former Soviet countries. as the Centers for Disease Control and Prevention, the Places most resistant to harm reduction are often National Academy of Sciences, and the National those with the highest levels of HIV infection among Institutes of Health, have studied needle/syringe IDUs. However, countries that have restrictive policies exchange programs and concluded that such programs but low HIV prevalence to date—countries such as reduce HIV transmission and do not increase drug use. Slovakia—may be sitting on a time bomb if they do not However, it is still controversial for U.S. policymakers increase effective harm reduction measures as soon to come out in favor of harm reduction approaches. as possible. This may be changing. As needle/syringe exchange HIV prevention advocates and service providers do and substitution therapy strategies continue to prove not necessarily have to wait for government funding and effective—and other interventions fail to adequately approval to begin implementing lifesaving programs. stem HIV infection among injection drug users— A harm reduction movement, usually at the local level, support for harm reduction is growing. Needle/ is under way in Eastern Europe and the former Soviet syringe exchanges and substitution therapy programs Union. Needle/syringe exchange programs are now operate in virtually all regions of the world. currently operating with the tacit permission of local Strong collaborative networks of harm reduction authorities even where national governments have not agencies are active in Asia, Australia, Europe, North officially endorsed such policies or effectively America, and South America. Multilateral agencies, decriminalized their methods. including the World Health Organization, UNDP, In addition to IHRD and the Soros foundations, and UNAIDS, support harm reduction as an other groups working to organize, fund, and sustain appropriate and reasonable response to the global harm reduction projects in the region include the AIDS epidemic. Central and Eastern European Harm Reduction Network, Canadian International Development Agency, Department for International Development (UK), ATTITUDES TOWARD HARM REDUCTION IN Medecins Sans Frontieres, UNAIDS, and UNDP. Even EASTERN EUROPE AND THE FORMER though the number of organizations involved continues SOVIET UNION to increase, the need for viable harm reduction Official acceptance of harm reduction varies throughout programs is rising even faster as injecting drug use the region. Many of the countries in Central and surges throughout the region.
THE BETTER ALTERNATIVE 23 III OSI’S LEADERSHIP IN THE HARM REDUCTION MOVEMENT
Homeless young people, many of whom sell both sex and drugs to survive, are particularly vulnerable to violence, abuse, hunger, and disease.
24 IHRD In 1995, the Open Society Institute (OSI), known for pioneering effective, innovative approaches to public health and human rights concerns, founded the IHRD program to support HIV prevention and other social care efforts targeting drug users in Eastern Europe and the former Soviet Union. Today, IHRD is a leader in the region’s struggle against the twin epidemics of injecting drug use and HIV. IHRD’s efforts are greatly strengthened by close coordination with a network of foundations established and supported by George Soros, who is also the founder and chair of OSI. Located in most countries of Eastern Europe and the former Soviet Union, the Soros foundations have joined with IHRD to develop on-the-ground networks of staff, contacts, and assistance critical to establishing effective harm reduction initiatives. Together, IHRD and the Soros foundations provide funding and support to 162 projects in 22 countries. These projects, based in local government and nongovernmental organizations, provide thousands of injecting drug users with potentially lifesaving services, including clean needles, counseling, and HIV prevention information. For the first time, IDUs who were once completely cut off from care are beginning to have access to medical, social, and psychological services.
HARM REDUCTION PROGRAMS THAT MEET LOCAL NEEDS While all projects that IHRD and the Soros foundations support adhere to the general philosophy of harm reduction, each is tailored to the specific political, legal, and social context in which it operates. Most provide needle/syringe exchange, since the most common substitution therapy, methadone treatment, is still illegal or too controversial in many countries in the region. Since patterns of drug use vary from place to place, projects themselves differ in the details of their service provision. On the next page are a few examples of the innovative ways that harm reduction programs are bringing help and hope to those long considered out of reach.
OSI’S LEADERSHIP 25 The Monar program in Kracow, Poland, has an Socium offers primary medical care, voluntary HIV established drop-in center with a long history of testing, and referrals to medical and legal providing drug users and their friends and family professionals. with resources such as counseling, treatment, and legal advice. Monar recently added a The Vilnius Substance Abuse Treatment Center in needle/syringe exchange component to its drop-in Vilnius, Lithuania, began the first methadone center and now conducts extensive outreach work treatment program in the former Soviet Union. In among active drug users. Monar helped to establish addition to methadone, the project offers a wide Kracow’s first methadone program and actively range of services including outpatient refers interested needle/syringe exchange clients detoxification, psychiatric treatment, general for methadone therapy. medical care, and referrals to employment agencies. Methadone clients at the center When the Initiative for Health Foundation started established a self-help group in 1999. Stable its harm reduction project in 1999 in Sofia, methadone clients, some with HIV, are employed as Bulgaria, it consisted of just a few outreach workers. outreach workers. These workers identified themselves by carrying distinctive bags as they circulated among drug users Harm reduction projects in Eastern Europe and the in a city park and neighborhoods where users former Soviet Union face multiple challenges, from congregated. The project eventually raised enough building trust with wary clients to dealing with funding for a van and now performs mobile repressive government agencies. Harm reduction needle/syringe exchange work in Sofia and within practitioners develop creative techniques to overcome Romani communities. It offers referrals to drug these obstacles. treatment programs and to clinics where users can get tested for HIV and hepatitis. Dragica Fojan, a harm reduction practitioner in Slovenia, organized opposition within the NGO In Poltava, Ukraine, the Charitable Anti-AIDS Fund community to a proposed anti-drug law that operates a needle/syringe exchange program. In promoted harsh penalties for users. Their advocacy addition to injecting equipment, the project offers helped defeat the measure. basic medical services, free condoms, counseling, and referrals to lawyers and health and mental Darko Kostovski, a physician in Skopje, Macedonia, health care professionals. The Fund’s staff receives sometimes wears a Star Trek uniform to coax a smile comprehensive training in HIV prevention and from clients entering the needle exchange program outreach work. The organization hosts a website on and put them at ease. HIV and drug addiction and produces a wide range of publications on drugs, HIV, sex, and drug-user Stefan Karabatic, a young outreach worker in Split, legal rights. Croatia, quietly contacts drug users at a coffeehouse and gives them clean injection equipment from his The Socium Harm Reduction Project in Bishkek, car without attracting the attention of the police. Kyrgyzstan, offers needle/syringe exchanges at two locations. Used syringes are counted, registered, In Odessa, Ukraine, outreach worker Sergey Kostin and destroyed in an incinerator. In addition, helps homeless people and drug users earn money
26 IHRD selling a newspaper his program publishes with needle/syringe exchange is already legal and politically contributions from local artists and writers. feasible, HIV-prevention materials and equipment, including condoms, bleach, and needles, are distributed to prisoners. In countries where IHRD SPECIAL INITIATIVES TARGETING needle/syringe exchange in prisons is technically AT-RISK GROUPS illegal, including Albania, Romania, and Turkmenistan, IHRD supports a number of special initiatives to reach groups are working to create a more receptive populations that are particularly vulnerable to HIV environment for harm reduction interventions. infection. Roma Sex Workers Several existing harm reduction projects are already In 2000, IHRD awarded grants for 34 projects that providing direct services within Romani communities. provide assistance to sex workers. Funding went to To perform this work more effectively and to better programs located in Belarus, Bulgaria, Estonia, understand harm reduction needs among Romani drug Hungary, Latvia, Lithuania, Poland, Romania, Russia, users, IHRD commissioned a study in three countries Slovakia, Turkmenistan, Ukraine, and Uzbekistan. and, with Monika Horakova, the only Romani member Support enabled existing harm reduction organizations of the Czech Parliament, organized a seminar on drug to add on or expand services targeting sex workers and use within Romani communities. The study and the helped sex-worker projects incorporate harm reduction seminar both underscored the importance of actively components. Most of the projects include engaging Roma in the design and delivery of needed needle/syringe exchange and outreach for sex workers; harm reduction services. To this end, IHRD hired a training for outreach workers on the special needs of technical advisor of Romani origin to help guide its sex workers; the development of health education and harm reduction efforts among Romani populations. HIV prevention materials; and legal and medical treatment referrals for women and men engaged in Street Kids sex work. The number of homeless children has grown markedly over the last decade in the region, most notably in Harm Reduction in Prisons Central Asia, Romania, and Russia. Lacking connection In response to the high rates of drug use and HIV to supportive families, access to caregivers or state-run transmission among prison inmates, IHRD recently social services, and protection, these children are launched a series of pilot harm reduction and HIV particularly vulnerable to violence, abuse, hunger, and prevention projects in prisons, funding 10 disease. Many engage in high-risk drug use and sell governmental and nongovernmental programs. Grants both sex and drugs to survive. went to programs in Albania, Estonia, Kyrgyzstan, Through a special partnership with the Canadian Latvia, Moldova, Poland, Romania, Russia, organization Street Kids International, IHRD arranged Turkmenistan, and Ukraine. for social workers and harm reduction practitioners These projects offer varied services, including from Tajikistan, Kazakhstan, and Kyrgyzstan to receive counseling for drug users and HIV education for training on outreach techniques targeting street kids. prisoners and prison staff. In countries such as Estonia, Participants learned about drug-use patterns among Latvia, Moldova, Poland, Russia, and Ukraine, where homeless children and methods to prevent HIV.
OSI’S LEADERSHIP 27 An MSF outreach worker discusses the harm associated with drug use at a metro station where users often congregate.
Harm reduction street workers counsel people cut off from caring relationships and offer them access to medical, social, and psychological services.
28 IHRD IHRD’S EFFORTS TO STRENGTHEN brought legislators together with drug policy LOCAL CAPACITY specialists from Eastern Europe and the United IHRD has sponsored hundreds of workshops, study States to help formulate national drug policies tours, research papers, and policy initiatives to based on scientific research and the practical strengthen local capacity in addressing drug use and experience of other countries. HIV issues through harm reduction. These efforts are creating a knowledgeable cadre of harm reduction practitioners and advocates as well as a small but EXISTING HARM REDUCTION EFFORTS growing number of government officials throughout the ARE NOT ENOUGH region who support harm reduction. Some specific The efforts of IHRD, the Soros foundations, and other initiatives include the following: partner organizations have helped build the foundation of an effective harm reduction movement in Eastern Organizing site visits for government and Europe and the former Soviet Union. Most notable have NGO representatives. For example, police been the tireless efforts of people at the local level, who representatives from Kazakhstan and Kyrgyzstan often face government authorities that are skeptical at visited drug treatment programs in Poland, best and oppressive at worst as they seek to establish where harm reduction measures are better projects addressing the urgent needs of drug users in established. regions that remain economically stagnant and socially hostile. Throughout the region, there are dedicated and Underwriting publications such as a how-to caring people—including workers and volunteers in the guidebook on establishing needle/syringe exchange nascent local NGOs and caregiver groups, many of projects and scholarly research on drug policy and whom are former or current drug users or people living ethnic minorities. with HIV themselves—who are willing to commit themselves to confronting the dire public health Implementing training programs for harm menace that is HIV. reduction practitioners on outreach work among These existing efforts, however, are small in minority communities, research and evaluation relation to the exploding rates of injecting drug use strategies, caring for women drug users, the sexual and HIV infection. Significant barriers—political, health of drug users, and organizational legal, and, most importantly, fiscal—remain in virtually development. all countries in the region. In the absence of consistent and diverse funding, substantive government support, Providing funds for key individuals from national and wider public acceptance, harm reduction efforts governments and NGOs to attend the annual will fail to contain an HIV infection rate growing faster International Harm Reduction Conference. than anywhere else in the world. Civil society, national and local governments, and the international Funding the establishment of local harm reduction community must act quickly before the window of advocacy groups such the Central and Eastern opportunity closes. Otherwise, in a region already European Harm Reduction Network. struggling to define itself and its future, hundreds of thousands of people, most of them young, will die. And Sponsoring roundtable policy discussions on drug- the chances of establishing democratic, open societies related issues. For example, in Georgia, IHRD may fade as well.
OSI’S LEADERSHIP 29 AFTERWORD: HARM REDUCTION PROGRAMS EXEMPLIFY OPEN SOCIETY VALUES
The mission of the Open Society Institute widely scorned and, as a consequence, are and the international network of Soros frequently neglected or subjected to punitive foundations is to transform what were closed treatment. In focusing on them, OSI’s harm or repressive societies into open societies. In reduction programs manifest our belief that addition, where the network operates in open the well-being of everyone matters. An open societies we assist those addressing flaws that society can only be built on a commitment to often involve disregard for marginalized the worth and dignity of all. Moreover, we segments of the population. Our aim is to consider failure to provide information and enhance individual autonomy for all to an care to those at risk increases the risk to extent consistent with our concern for the others. autonomy of others. The Open Society Institute operates a The Open Society Institute supports harm broad range of programs. We promote the rule reduction programs because they exemplify of law. We support independent, diverse, and values that are central to our mission. These high-quality media, and the dissemination of programs provide individuals at risk an information and ideas through electronic opportunity to minimize the damage they means. We operate economic development suffer because of their drug addiction or their programs to support transition to market sexual practices by reducing exposure to HIV economies that address the needs of all and to opportunistic diseases such as TB that citizens. We attempt to enhance educational are often lethal to those with impaired opportunities from early childhood through immunity. In the process, we believe that advanced university instruction. We assist harm reduction programs also contribute to those promoting the rights and opportunities general social welfare by limiting the spread of of women and of minorities suffering from these diseases throughout the population. discrimination. We foster the development of The injecting drug users, sex workers, and democratic institutions. We promote public the sexual partners of both groups who are the health. Much of our work is conducted in the main targets of harm reduction programs are formerly closed countries of what was the
30 IHRD Soviet empire, but increasingly we also comprehensive effort to advance our mission operate programs in other parts of the world: by fostering the development of open sub-Saharan Africa, Southeast Asia, the societies. Middle East, the United States, and a few other countries of the Western hemisphere. Aryeh Neier The work of the International Harm Reduction Development program and its President grantees is an intrinsic part of our Open Society Institute
An open society can only be built on a commitment to the worth and dignity of all.
AFTERWORD 31
DIRECTORY
HARM REDUCTION PROGRAMS
IN EASTERN EUROPE AND
THE FORMER SOVIET UNION Harm Reduction Programs in Eastern Europe and the Former Soviet Union
The International Harm Reduction Development (IHRD) program of the Open Society Institute (OSI) funds a growing number of projects throughout the region targeting IDUs and others most at risk for contracting potentially fatal diseases such as HIV and hepatitis C. The projects all meet the basic IHRD criteria of providing needle/syringe exchange and extensive outreach and education services in a nonjudgmental manner. A few of the projects are linked to organizations that provide methadone maintenance therapy (and most others provide referrals when requested), but the main IHRD goal remains to prevent the spread of HIV in the most basic ways possible among people who continue to inject drugs. IHRD funds harm reduction projects at some 130 organizations from Bishkek, Kyrgyzstan, to Split, Croatia. IHRD approval and commitment are usually contingent upon the availability of additional funding from NGOs, local government agencies, international aid organizations, and other sources. The number of clients served by the harm reduction projects varies widely depending on the size of the organization and the target population. In large cities such as Odessa, Ukraine, more than 1,000 people a month regularly exchange needles and use the local project’s other services. Meanwhile, across the country in tiny Uzhgorod, fewer than 100 clients are in regular monthly contact. IHRD funds 11 projects that focus solely on harm reduction in prisons since, in several countries, the highest rates of drug use and HIV are among prisoners. After surmounting the initial hurdle of approval from authorities to implement the projects (including the controversial needle exchange elements), organizers face substantial logistical and trust problems inside prison walls. The most successful ones have established peer education systems not only for prisoners but also for staff, whose tolerance is vital. Another priority is sex workers, whose numbers are growing
34 IHRD steadily in Eastern Europe and the former Soviet Union. Many sex workers are also injecting drug users, increasing their risk of contracting HIV and hepatitis. They are usually concentrated in larger cities and border regions along with other transient populations that are more likely to use drugs. IHRD funds 34 sex worker projects. About two-thirds were funded by “add-on” grants to projects that already received separate support for harm reduction services to IDUs. The other third went to organizations that worked with sex workers but had not previously focused on harm reduction services. As with other harm reduction projects, the first step in serving sex workers is prevention education followed by convenient access to condoms in tandem with clean needles. Some projects try to set up individual monitoring systems, recognizing that sex workers are more migratory than other groups and often face different types of dangers. Clients can also be referred to knowledgeable health care specialists who pledge to guarantee anonymity. HIV rates among IDUs have dropped considerably in a number of cities where projects have gained the trust of the drug-using community, not a simple task. Elsewhere, though, rates continue to rise as the IDU population skyrockets—there are always new, young users who are unaware of risks or just do not care about them. Nearly every project, however, has had a demonstrably positive effect on how IDUs and people with HIV are viewed by local officials and the general public. Newspaper and TV stories about the projects have opened people’s eyes and led to increasing support for the sort of harm reduction strategies funded by IHRD. The next step may be a commitment on the part of health care authorities to adopt similarly aggressive measures to combat HIV before it becomes a much larger, and more expensive, social health problem. That in turn could lead to a more understanding attitude toward drug use and abuse and the people at the heart of the issue.
DIRECTORY 35 Albania Belarus
Aksion Plus and Albanian Youth Council Byelorussian Patriotic Union of Youth Rr. Asim Vokshi: Nr. 56 Olhovskih Street, 8 Tirana, Albania Pinsk 225710 E-MAIL: [email protected] Belarus Drug use is illegal under Albanian law, but it has risen E-MAIL: [email protected] sharply in tandem with drug smuggling during the Needle exchange, which is legal in Belarus, is considered ongoing political, economic, and social changes an effective public health policy by the national program following the collapse of the communist regime. on HIV prevention. There are about 75 people with HIV Anecdotal evidence indicates that just about every in Pinsk, the majority of whom are IDUs. About 80 person in Tirana now knows at least one young person percent of IDUs reuse needles and syringes multiple who is a habitual heroin or barbituate user. There are no times without disinfecting them. methadone treatment programs in Albania and only one The project, which has the support of local health licensed detox center. authorities and the police, is part of a larger UNDP The project relies on aggressive outreach efforts program, “Expansion and Consolidation of HIV and peer education training to build trust among clients, Preventive Interventions among IDUs in Belarus.” many of whom do not venture far from their homes out Similar projects have been set up in Svetlogorsk, of fear of the police and the gangs that control the drug Mogilev, Minsk, Vitebsk, and Soligorsk. The project has trade. It is also collecting data about drug users’ forced city authorities to recognize the severity of the behavior and the risk factors that are specific to Albania, drug problem and the necessity of supporting harm which it will share with the government and other NGOs reduction measures to prevent HIV infection. The where appropriate. number of IDUs using the project’s services is increasing steadily.
Stop AIDS Rr. Qemal Stafa, P.8, Sh.1 Center of Hygiene and Epidemiology Tirana, Albania Kozlova Street, 68 E-MAIL: [email protected] Soligorsk 223710 Stop AIDS is an NGO with longtime experience with Belarus AIDS prevention work, especially with high school and E-MAIL: [email protected] university students. Its prison project focuses on The city government supports and participates in the increasing prison administration knowledge and project’s efforts. The project manager is a member of support of HIV/AIDS prevention; training prisoners the city council, and another employee has been about HIV prevention; creating peer education groups appointed to the city committee on HIV prevention. among prisoners; identifying at-risk groups; and Together with the Public Health Center, the project providing HIV-prevention equipment and materials as conducts awareness seminars for different citizen needed. groups. Local police and the media are also supportive. Outside prison walls, the project focuses on Preliminary research indicates that most IDUs in the prisoners’ rights, particularly those regarding health region share needles and do not use condoms, but that care, access to prevention education, and social support many have adopted harm reduction strategies since the and counseling. It also closely evaluates legislation on project began. HIV/AIDS in prison.
36 IHRD Liberal-Democratic Youth Union NGO “Vstrecha” Sharangovich Street 39 P.O. Box 52 Minsk 220020 Minsk 220012 Belarus Belarus E-MAIL: [email protected] E-MAIL: [email protected] Belarus officials first took aggressive action against As rates of sexual transmission of HIV begin to rival rapidly expanding drug use in 1997, when a new those of drug use, both male and female sex workers face government policy was unveiled that supports harm additional risks. Vstrecha’s sex worker project relies reduction efforts. In Minsk, the capital and largest city, heavily on extensive outreach efforts and behavioral there are some 15,000 IDUs. About 65 percent of people research. It provides needle/syringe exchange to drug- with HIV are drug users. using sex workers as well as condoms, lubricants, and The project operates two needle exchange centers. counseling services to all clients. The project plans to One is an unqualified success; the other, however, is still publish a comprehensive study based on its activities struggling to attract enough clients to make it viable. that could be used for future projects elsewhere in the Project directors expect to make a concerted effort to region. increase the number of clients at the struggling center. The organization, which was founded in 1995 If that effort fails, they plan to shift resources to the primarily to provide HIV awareness and prevention other center. services to men who have sex with men (MSM), often works closely with the National Center for AIDS Prevention. One of the organization’s major challenges Mogilev AIDS Center is to reduce social stigma surrounding MSM and IDUs, Mechnikova Street, 6 among other marginalized groups. Mogilev 212008 Belarus E-MAIL: [email protected] Parents for the Future of Children The project currently serves more than 800 clients a 4 Shkolnaya Street month, most of whom are male IDUs or men who have Svetlogorsk 247400 sex with men. The Belarus Ministry of Internal Affairs Belarus and other state agencies support the project, which is E-MAIL: [email protected] credited with helping reduce HIV infection and Although the country’s drug laws prohibit the influencing public health policy in the region. production, possession, and sale of drugs, drug use itself and needle exchange programs are not prohibited. IDUs can buy disposable syringes at pharmacies without a doctor’s prescription. Parents for the Future of Children, Belarus’s first harm reduction program, serves more than 2,700 clients a month. Local authorities, including the police, are increasingly supportive of harm reduction measures. A decrease in the sharing of dirty syringes has brought about a corresponding decrease in the number of clients with hepatitis, abscesses, and ulcers. The number of IDUs using condoms during sexual intercourse has increased.
DIRECTORY 37 Vitebsk Women’s Club Bulgaria Box 112 Vitebsk 210038 21st Century Foundation Belarus 25 D. Konstantinov, fl. 4 E-MAIL: [email protected] P.O. Box 347 The project offers standard harm reduction services, Pleven 5800 including needle exchange for IDUs and sex workers, as Bulgaria well as HIV and hepatitis tests and referrals to doctors, E-MAIL: [email protected] psychologists, and legal counselors. The project runs a A national drug law passed in 1999 gave official support comprehensive HIV awareness program for young to harm reduction efforts, so legal obstacles no longer people and engages in advocacy work with government exist. The project’s work has the approval of the local officials and the media. Support from local authorities government, health care facilities, the police, the media, has been extensive: rent, utilities, and disposal of used and other drug-use organizations. Project officials syringes are provided free of charge. report a growing HIV prevalence among their clients, There is a strong demand for project’s services. although it remains relatively low. The project has made Clients report feeling that someone now cares about many solid contacts with the IDU community, beginning them, and they are often willing to take an active the process of gaining their trust. part in project activities. Although IDUs show an increasing level of knowledge about HIV, a gap between knowledge and behavior still exists. A core group of drug Dose of Love Association users will not participate in needle exchange for fear Slavejkov, Bl. 11, entr. 3 that others will learn of their drug use. P.O. Box 14 Burgas 8005 Bulgaria E-MAIL: [email protected] Burgas is a resort area as well as a major cultural and industrial center. During the summer, drug users from other parts of the country and other nations often visit. The estimated number of resident IDUs in the city has risen sharply in recent years, to 1,500. The project targets them and sex workers. Dose of Love has established strong relationships with other local institutions, including a detox facility, the Institute of Public Health and Epidemiology, the police, and the media. It also collaborates with the Department of Social Work at the Burgas Free University, offering students the opportunity to volunteer at the association.
38 IHRD Health and Social Environment Foundation Croatia 17, Macedonia Blvd., 4th floor, A-21 Sofia 1606 Croatian Red Cross Bulgaria Crveng Kriza 14 E-MAIL: [email protected] Zagreb 10000 The project builds on the foundation’s work with Croatia commercial sex workers in the border regions of E-MAIL: Sinisa. [email protected] Bulgaria since the mid-1990s. The main short-term Despite still-repressive national laws regarding drug objectives center on expanding harm reduction outreach selling and possession, the authorities have accepted to five areas in Sofia where prostitution is common and harm reduction as part of a national health and social working with sex workers in the Romani community. In welfare strategy. The media and the general public have the long run, the project seeks to reduce social stigma become more supportive the more they learn about toward sex workers and increase its ability to monitor harm reduction. Relatively few IDUs in Croatia are HIV clients who migrate frequently based on working positive, but the rate of hepatitis C among IDUs is conditions. almost 80 percent. The agency operates needle exchange projects in Pula and Zadar as well as Zagreb, collaborates with harm Initiative for Health Foundation reduction projects elsewhere in Croatia and in P.O. Box 56 neighboring countries, and recently expanded its efforts Sofia 1335 to include information about drugs such as ecstasy. Bulgaria E-MAIL: [email protected] The project serves nearly 600 IDU and sex worker HELP clients a month, but that number is expected to increase Mihovilova Sirina 1 since there are an estimated 10,000 regular heroin users Split 21000 in the city alone. Services for IDUs are relatively few but Croatia improving: a methadone maintenance program was E-MAIL: [email protected] recently begun, and the government started a mobile The project, which began in 1996 and enjoys strong needle exchange program and plans to increase health public and local government support in Split and other and counseling services. The project has conducted nearby cities, cooperates with several organizations that outreach in Sofia’s Romani community, the first time a provide various services for drug users. More than 500 health service has focused specifically on that new clients are served each month. Although few are population in Bulgaria. HIV positive, some 50 percent are infected with hepatitis B and 7 percent with hepatitis C. Most clients appreciate the needle/syringe exchange service and take additional steps to try to improve their health.
DIRECTORY 39 Czech Republic NGO Sananim Novovysocanska 604 A Drop In O.P.S. — Center for Methadone Praha 9 - Vysocany 19000 Substitution Czech Republic Karoliny Svetle 18 E-MAIL: [email protected] Prague 1, 13000 The project operates in central Prague and surrounding Czech Republic areas, offering counseling, crisis intervention, referrals, E-MAIL: [email protected] basic health care, and social work services in addition to The project serves about 300 clients a month. Its needle exchange. Many of its volunteers are former and outreach work extends to other cities in the Czech current clients. The project publishes a magazine, Republic with significant concentrations of IDUs. The Dekontaminace, about drug users’ concerns, and it has low rate of HIV and hepatitis infection in Prague is due started outreach programs in area prisons. at least in part to the project’s aggressive harm reduction A typical client first comes to the project after using efforts, which include free testing and referral to drugs for about two years. He (the vast majority are treatment programs. male) generally lives at home with his parents, works A potential obstacle is the growing anti-drug or still goes to school, and does not necessarily believe sentiment in the country. Politicians and the general that there is a problem with using. Changing such public have grown concerned by what they believe to be attitudes is a long-term process; the project initially the involvement of high-level criminals in the drug focuses on standard harm reduction strategies, the core trade. A new, more prohibitive national drug law and of its mission. more repressive police action are pushing drug users further underground, hampering the project’s outreach efforts. Some newspapers, however, support harm Struzeni Podane Ruce reduction strategies and criticize police and politicians Videnska 3, 639 00 for their harsh drug-use policies and practices. Brno 61200 Czech Republic E-MAIL: [email protected] Drug Out Club The project serves some 600 clients a month, of whom Stará 1 nearly 50 percent are hepatitis C positive. Clients have Usti nad Labem 40001 been enlisted to do some of its street work, including Czech Republic outreach to IDUs who are difficult to reach, such as E-MAIL: [email protected] those in the Romani community. The local government and medical facilities have Harm reduction programs are supported by the city supported the project since its inception in 1996. of Brno and the Czech government, but the project is Many clients are referred to social service agencies for presently the only one providing such services in the additional counseling as well as to the regional job region. There is concern that the new, harsh national center, where they can receive employment training. criminal law regarding drugs may deter drug users from The project, with some 800 clients a month, faces establishing contact with the center and other increasing demand for its needle exchange services and organizations that work with drug users. condom distribution. It has expanded its in-house medical services unit to help provide basic care. With the trust of much of the local IDU community, it plans to focus on reaching sex workers.
40 IHRD Estonia Hungary
AIDS Information and Support Center Salamon Alapitvany Narva Street 48 Balastya 6764 Tallinn 10150 Hungary Estonia E-MAIL: [email protected] E-MAIL: [email protected] The number of sex workers in Hungary has increased The center runs three separate harm reduction projects, steadily over the past decade in the wake of the collapse one a needle exchange program (NEP) mainly serving of the Soviet Union and the decriminalization of IDUs, one focusing on sex workers, and the third a prostitution in 1993. The concurrent rise in drug use prison project. The NEP reaches drug users throughout has created a large at-risk population of sex workers the country, in particular the three largest cities of who receive few services. Tallinn, Narva, and Tartu. Each month, nearly 350 The project operates mainly in southern Hungary, clients participate in the needle exchange program while along major trucking routes and other areas where sex some 900 are served by the center’s methadone workers congregate. It provides individual counseling maintenance program. and referral services and works closely with the Ministry The number of IDUs who regularly exchange of Health and the South Hungarian Harm Reduction needles/syringes has doubled in the past year as drug Union (SHHRU) to offer needle/syringe exchange and users have begun to trust the staff and take part in harm reduction information. prevention work themselves. Several IDUs from a local rehabilitation center participated in a lecture to young people about HIV and drugs, and the center hopes to Southern Hungary Harm Reduction– expand such outreach efforts. Youth Drug Center Fesu u. 4 Szeged 6726 Hungary E-MAIL: [email protected] The program was one of the founding members of the Central-Eastern European Harm Reduction Network. It currently serves about 250 clients a month and is increasing its outreach efforts and services, including domestic and international advocacy on behalf of harm reduction strategies. Although the program has developed relationships with regional and national medical and social service organizations, it still must deal with skeptical authorities. Official policies toward drug use are repressive and punitive, and authorities focus on abstinence-based services, which are limited and not particularly useful.
DIRECTORY 41 Kazakhstan Imaton Aiteke-bi, 46, fl. 22 Akmolinsk Oblast AIDS Prevention and Aktobe 46300 Control Center Kazakhstan Kokshetau, Akmolinsk Oblast 475000 E-MAIL: [email protected] Kazakhstan Of the more than 1,000 people in Kazakhstan estimated E-MAIL: [email protected] to be HIV-positive, at least 90 percent are IDUs. The harm reduction project marks the first time this Authorities and NGOs expect to see a major increase in government agency has aggressively moved beyond its HIV cases as drug use spreads, especially among education efforts in the region’s schools and youth adolescents unfamiliar with the concept of harm centers. The center implemented the project in reduction. Imaton has taken steps to address the response to the huge increase in drug use among young looming crisis by conducting educational meetings for people, especially the unemployed and poor, and the students and teenagers across the city. lack of viable social services for drug users in Kokshetau. The project’s biggest challenge is to convince drug Few drug users are aware of the risks of HIV and users to overcome their fears (of the police or of losing hepatitis from either sharing works or unprotected sex. their anonymity) and to visit the center regularly. Local The project has opened two needle/syringe media, law enforcement authorities, and government exchanges where clients can also receive condoms and agencies have begun to play more extensive roles in medical information. It hopes to create a peer education spreading the word about the project and providing system with former and current IDUs at the forefront of additional support. outreach efforts.
Kzyl-Orda Oblast AIDS Prevention and Dvizhenie Control Center Gaidar Youth Library 7 Shukurov Street 166 Lenin Library Kzyl-Orda 467021 Uralsk 417002 Kazakhstan Kazakhstan E-MAIL: [email protected] E-MAIL: [email protected] Although only a handful of cases of HIV have been The city of Uralsk sits along a major drug-trafficking reported in the Kzyl-Orda Oblast (district), surveys route from Asia to Europe, not far from Russian cities indicate that more than half of IDUs are infected with with some of the highest HIV prevalency rates in that hepatitis B or hepatitis C (or both). Experts expect those country. As a result, the number of IDUs in the Uralsk numbers to increase because more than 80 percent of region has risen sharply in recent years. Few IDUs still share needles and condoms are too expensive government resources are available for drug users; the for most people, especially the unemployed and poor. project’s harm reduction service is the only one of its The project plans to expand to areas outside the city and kind in the area. to increase its education and referral efforts to help The project cooperates with the local Narcological stem the growth of STIs and diseases such as Center and the AIDS Prevention and Control Center in tuberculosis. organizing educational outreach among clients and young people in the region. The media and the government have also been supportive, with the latter providing free housing and transportation.
42 IHRD NGO “Credo” Kyrgyzstan Anzherskaya Street, 37 Karaganda 470032 Main Department of Harm Reduction Kazakhstan Bishkek 720064 E-MAIL: [email protected] Kyrgyzstan The project tracks and records information about the E-MAIL: [email protected] IDU community in order to tailor services to the needs The project aims to reduce the spread of blood-borne of clients. Participating doctors frequently refer patients diseases and STIs in Kyrgyz prisons, where a to local facilities for detox treatment and counseling. disproportionate number of the country’s IDUs live. With the use of a mobile unit, the project plans to extend Prison medical and psychological staff receive its outreach efforts to remote and underserved parts of specialized training on HIV and hepatitis, and peer the city. Credo cooperates with the regional AIDS center, educators help spread the word on safer behavior to the public health services, and the city’s Department of prisoners themselves. Project workers hope to set up Education. support groups for prisoners and staff, anonymous and confidential HIV testing, and assistance and referral information for inmates being released. Public Foundation “HELP” 5th of April Street, 67 Kostanai 45800 NGO Socium Kazakhstan Fuchka Street, 24 E-MAIL: [email protected] Bishkek 720054 Although local officials profess support for the program, Kyrgyzstan many people, including health care workers, view drug E-MAIL: [email protected] users in a negative light and remain skeptical of the Kyrgyzstan is situated on the main drug-trafficking value of harm reduction. The project has conducted route from Afghanistan and Pakistan to the West. Since harm reduction seminars for the police, and hopes to poverty and unemployment are high, the illegal drug expand its efforts to other government agencies and trade involves many people in Bishkek and other Central organizations. Counseling for clients and their families Asian cities. Women and children, increasingly and friends is also available through a hotline. employed as drug couriers and to solicit new customers, Clients are now more aware of the risks of drug use are usually paid for their work with drugs. The majority and some have begun exchanging needles regularly, but of IDUs in Kyrgyzstan live in or near Bishkek, the capital the level of misinformation and ignorance in the area and largest city. remains high. An estimated 92 percent of the Kostanai The project serves about 500 clients a month, region’s IDUs share drugs, with 79 percent re-using offering them basic medical care and assistance from syringes. Some 72 percent are unaware of how HIV is narcologists, psychologists, and lawyers. The city and contracted and, when told, are rarely concerned. provincial administrations support the project and Seventy-eight percent of the project’s clients practice provide funding; the project hopes to secure federal unsafe sex on a regular basis. support as well.
DIRECTORY 43 Osh Narcology Dispensary Latvia 39 Nabiev Street Osh 720000 AIDS Prevention Center of Latvia Kyrgyzstan 7 Klijanu Street E-MAIL: [email protected] Riga 1012 Drugs are quickly becoming an integral part of life in the Latvia Osh region, due in large part to its geographical E-MAIL: [email protected], [email protected] proximity to the often porous borders of several Central The center operates both a needle exchange program Asian countries. By unofficial estimates, about 40 to 50 (NEP) and a prison project. The former, partially funded percent of the Osh population is somehow involved in by the federal government, serves IDUs and sex workers the drug trade, resulting in growing drug use as well in Riga and two nearby cities. Most of Latvia’s estimated (with users becoming younger and younger). HIV is not 15,000 IDUs live near Riga, which is a major port and a huge problem, but with up to 10 users commonly transit point for drug trafficking to the West. For detox sharing one needle, the potential for an epidemic is services, HIV testing, and advanced medical care, clients high. are usually referred to the local Narcological Center. Local authorities understand the problem, with city The prison project seeks to stem the rapidly and provincial administrations contributing to the growing number of prisoners with HIV, who now project, but the general public is expected to be rather represent at least 20 percent of Latvians living with the slow in changing its attitude toward drug use and harm virus. Until recently inmates received little or no reduction. Specialists from Europe evaluated the project information about safer drug use or safer sex. The and called it the most effective in Asia. The key has been project provides prisoners with free access to bleach and the ability of project staff to win the trust of drug users condoms; educates them about HIV through peer and convince them to use the project’s services groups; and promotes understanding among frequently. correctional staff about harm reduction techniques. It also seeks to increase cooperation between Latvia’s public and prison health services to better coordinate a response to the issue of HIV in prisons.
44 IHRD Lithuania Vilnius Substance Abuse Treatment Center Gerosios Vilites, 3 Deliverance Vilnius 2009 Gardino 22-10 Lithuania Druskininkai 4690 E-MAIL: [email protected] Lithuania Needle exchange, though legal in Lithuania, is not E-MAIL: [email protected] officially promoted. However, as the center has become The organization offers both methadone maintenance more visible in its work, the general public’s tolerance treatment and needle/syringe exchange services. Both and support of harm reduction strategies has increased. programs offer prevention education, testing for HIV Outreach workers, who make contact with IDUs and sex and hepatitis and health and counseling services. workers on the streets and provide information and Clients also receive help in obtaining missing official advice as well as clean works, are recruited from stable documents, finding jobs, and rebuilding important clients of the center’s methadone maintenance program. social skills. The methadone treatment program, the first to be In its first year, the project experienced opposition established in the former Soviet Union, has nearly 500 from the personnel of two schools near the project’s clients who receive substitution treatment, outpatient drop-in center. However, the police and other detoxification, counseling, testing for HIV and hepatitis, organizations have been largely helpful and supportive. and general health care. Clients can also take advantage Among the groups working with the project are Save the of legal, psychological, and employment services, and Children, the Vilnius Narcological Center, the they can participate in a self-help group. The project’s Druskininkai Primary Health Care Center, and the viability proves that general practitioners can European Federation of Therapeutic Communities. successfully treat drug users with the support of specialists.
Klaipeda Drug and AIDS Prevention Group (KDAPG) Visaginas Mental Health Center Taikos Prosp. 46 Taikos, 15 Klaipeda 5802 Visaginas 4761 Lithuania Lithuania E-MAIL: [email protected] E-MAIL: [email protected] The KDAPG operates its needle exchange project jointly Visaginas has one of the highest number of drug users in with a government agency, the Klaipeda Addiction Lithuania. One reason is the closing of the Ignalina Treatment Center, which runs the city’s methadone Nuclear Power Plant, which caused unemployment rates maintenance clinic. Klaipeda, Lithuania’s main port, has to skyrocket. Low rents in Visaginas also attract drug one of the country’s highest drug-use rates. Under a users from Vilnius and other cities. The center’s harm verbal agreement with city police, outreach workers can reduction work has the support of city officials and distribute syringes and needles freely in all parts of the community members. Various doctors, social workers, city, including places where illegal drugs are prepared and mental health professionals provide clients with and sold. Every outreach worker carries a Harm free and anonymous consultations. The center is linked Reduction Program Worker Card. to the Lithuanian AIDS Center and the Vilnius The number of new clients with HIV increased Narcologic Clinic. sharply in the first few years of the project, but it has recently declined—an indication of the effectiveness of harm reduction programs in the city.
DIRECTORY 45 Macedonia Via Vita Center for Civic Initiative Anesti Popovski 10/1/8 Healthy Options Project Skopje (HOPS) Bitola 7000 Dvarska No. 1 Macedonia Skopje 1000 E-MAIL: [email protected] Macedonia Drug use has increased steadily in the Bitola region E-MAIL: [email protected] of southeastern Macedonia over the past few years, In recent years, Macedonia was buffeted economically especially among young people. The project’s main goal by conflict and social disruption in neighboring is to educate IDUs and sexually active teenagers about Yugoslavia and increasingly tense interethnic HIV, hepatitis, and STIs and to provide them with harm relationships. These factors contributed to the reduction tools when needed. Street outreach and continuing rise in the number of drug users, most of counseling services are available every day. them young and poor. HOPS, operating in Skopje since A project priority is to explain harm reduction to 1997, conducts HIV education programs in local schools civic leaders and organizations in Bitola and nearby and works with local media to raise awareness in the communities in order to gain support. The project general population. It has successfully increased its established a team of experts, including psychologists secondary exchange activities and stepped up efforts to and social workers, to build a network of local NGOs and provide clients with information on civil rights and government agencies that can provide useful services to available medical assistance. drug users.
Izbor Atanas Nivicanski 6 Strumica 2400 Macedonia E-MAIL: [email protected] Of the estimated 1,000 IDUs in the Strumica region, more than 65 percent are thought to have hepatitis C or B, or both. The project seeks to bolster its harm reduction efforts by helping improve relationships and communication between clients and their families. It cooperates closely with the local medical center and other social service NGOs and has held workshops on HIV and hepatitis in local schools. The project plans to increase its outreach efforts among the sizable Romani community in the region.
46 IHRD Moldova NGO Anti-HIV Testemitanu 27 Adolescent Education Center Chisinau 2025 Scrisul Latin Street 13 Moldova Orhei 3500 E-MAIL: [email protected] Moldova The organization does not offer needle exchange, but it E-MAIL: [email protected] does provide informational assistance to health care In addition to needle/syringe exchange and condom professionals and groups that work on drug use and distribution, the project offers anonymous HIV testing, AIDS issues. So far it has established connections with drug counseling, safer-sex and drug-use education, and all harm reduction projects in Moldova, published a hotline. It has received support from the city documents that are circulated to some 10,000 people, government, the police department, the district and established a website (http://www.hr.mednet.md). hospital, and a local family planning center—as well as It cooperates closely with the National AIDS Center and from international groups such as Save the Children and various United Nations organizations including the Peace Corps. UNICEF. Although the project only opened in 2000, client numbers are above expectations as IDUs seek out its services and spread the word. Many of the clients are NGO Educational Center: Drug and young people at risk for a variety of social and medical Alcohol Addiction ills, including child abuse, depression, and suicide. Igor Minascurta 1 The project offers counseling referrals and other Soroca 3000 psychological support services. Moldova E-MAIL: [email protected] Due in part to its location near bigger Moldovan cities National Center for AIDS Prevention and the Ukrainian border, Soroca has a relatively large and Control IDU population. Many of the IDUs are members of the Stradela Studentilor 7/1 local Romani community, which has traditionally had Chisinau 2020 little contact with the national health system. During the Moldova first two years of the project’s existence, there were no E-MAIL: [email protected] new HIV/AIDS cases among IDUs in the Soroca region Staff and volunteers have set up relationships with other and the hepatitis rate slowed considerably. The project harm reduction projects in Poltava, Ukraine, and has plans to add new services, including a hotline and a Mogilev and Svetlogorsk, Belarus—which have been mobile needle exchange unit. useful in helping organizing the needle exchange program in Chisinau. The center has established links with the Ministry of Internal Affairs, the Ministry of Education, and the Chisinau Health Department as well as with UNAIDS. Government financial assistance, however, is expected to be minimal as the country struggles to arrest a decade-long economic downturn and related social dislocation. According to recent data, Moldova is now the poorest country in Europe, edging out long-time leader Albania.
DIRECTORY 47 NGO Health Reforms in Penitentiary Youth For the Right to Live Institutions P.O. Box 27 35 Titulescu Street Balti 3121 Chisinau Moldova Moldova E-MAIL: [email protected] E-MAIL: [email protected] The project has forged close relationships with local The project, in coordination with other prison-oriented health care and law enforcement authorities—the NGOs and the National Center on AIDS Prevention, is Disease Control Center destroys its used syringes for working toward implementing a long-term, coordinated free, for instance—and it plans to boost referrals to strategic approach to HIV/AIDS and drug use in prisons. detox centers and other social service agencies. The main goals are to make education and training on Aggressive outreach and positive word of mouth have HIV prevention available throughout the entire increased the number of regular clients. The next step is penitentiary system; provide bleach, condoms, and to gain the trust of the most suspicious users, most of medicine for the treatment of STIs to all inmates; and whom fear loss of anonymity more than potential allow inmates with progressive life-threatening infection from HIV or hepatitis. diseases, including AIDS, to be released early.
Together to Save the Future Toma Ciorba 3 Falesti 5903 Moldova E-MAIL: [email protected] A provincial capital in northwestern Moldova near the Romanian border, Falesti suffers from many of the same social ills affecting other cities in the economically struggling region. Poverty, boredom, and isolation prompt many young people to turn to hard drugs, which circulate widely through Moldova on their way to even more lucrative markets in Western Europe. The project’s harm reduction strategies include needle exchange, condom and disinfectant distribution, and other medical, educational, and psychological services. The foundation collaborates with the city government, the local police, and the AIDS center. It receives technical assistance from another NGO, Spectrum.
48 IHRD Poland Drug Addiction Treatment Center for Families (MONAR Warsaw) Association for Social Prophylactics ul. Hoza 57 (SEDNO) 00-681Warsaw al. Marcinkowskiego 21 Poland 61-745 Poznan E-MAIL: [email protected] Poland The Warsaw project is one of MONAR’s 10 needle E-MAIL: [email protected] exchange programs in Poland—and now one of its Drug use among young people has risen sharply in the busiest. An estimated 60 percent of its clients may be Poznan region. Recent data estimate that there are infected with HIV and/or hepatitis C. Clients’ trust in nearly 1,000 people with drug addictions in the city; the project has grown steadily: when it began, just 30 more than 15 percent are thought to be HIV positive. The percent of new needles were returned, but now nearly project is collecting data from clients in an effort to put 90 percent of needles and syringes are brought back and together the first comprehensive report on IDUs and exchanged. their habits in Poznan. The project also focuses outreach The project works with several other local social efforts on the sex worker and homosexual populations, service organizations. Once a week it conducts a joint distributing condoms and HIV education materials. outreach effort with a group called Street Workers for Sex Workers, and it seeks out and reserves shelter space for homeless sex workers and IDUs. AZYL Association ul. Mlynska 2 58-400 Kamienna Gora Lublin Social Association Poland ul. Zachodnia 17 E-MAIL: [email protected] 20-620 Lublin Poland About 50-70 clients a month are served by the project, E-MAIL: [email protected] which offers counseling before and after HIV testing, in addition to needle exchange and condom distribution. The association operates a needle/syringe exchange AZYL has also established educational projects in the program (NEP) and a methadone maintenance program. region and is working to build relationships with state The NEP focuses many of its resources on Pulawy, a health services and other NGOs in Kamienna Gora. town of 50,000 near Lublin that has the largest Local authorities have begun helping out financially, concentration of drug users in the region. In 1997, soon and, for the most part, the general public has accepted after the project started, 82 percent of its clients were the project. HIV positive and an even higher percentage tested positive for hepatitis C. Those percentages are thought to be much lower now. The Lublin detoxification department has not received a single patient from Pulawy with post-injection complications since 1996. More than half of the methadone program’s clients are infected with HIV, and 98 percent have hepatitis C. Although the association works closely with other NGOs and government agencies, it reports significant resistance. Some seem more intent on not losing clients than actually providing them with harm reduction strategies.
DIRECTORY 49 MONAR Drug Addictions Center MONAR Krakow ul. Sudecka 11 Krakow Association of Assistance to Drug Users 58-500 Jelenia Gora Polish Harm Reduction Network Poland ul. Sw. Katarzyny 3 E-MAIL: [email protected] 31-063 Krakow The project’s three-person outreach teams attempt to Poland locate IDUs who are unable or unwilling to drop by the E-MAIL: [email protected] center. The project offers harm reduction materials and Four separate harm reduction projects are operated out related services, and it is organizing a network of of one office in Krakow: a needle exchange program assistance centers and family-support programs. The (NEP), a harm reduction information clearinghouse, a rate of HIV and hepatitis infection among IDUs and prison project, and a sex worker initiative. Polish law is adolescents has slowed since the project began. The quite strict regarding drug use, requiring arrests for the number of clients using the project’s services has possession of even small quantities, but the projects’ continued to increase. clients do not normally face major difficulties from the The project is cooperating with the city’s welfare police when using their services. authorities regarding benefits for IDUs and their MONAR Krakow’s NEP is the oldest, having been families. It also works with the regional employment started in 1996. While HIV infection has not made major office for job placement services and with a local group, inroads among its clients, an estimated 80 percent of the Dolnoslaska Sickness Fund, for drug treatment. IDUs in the city are infected with hepatitis C (and it is estimated that 75 percent of them were infected during their first year of injecting). The project has introduced MONAR Gdansk marked syringes as part of an effort to track usage ul. 3 Maja 6 patterns. 80-802 Gdansk The Polish Harm Reduction Center provides up-to- Poland date harm reduction information and analysis. Its E-MAIL: [email protected] prevention and education newsletter, MONAR On the With the cooperation of penal authorities, the project Jumble, is distributed to people who work on drug issues has expanded its harm reduction efforts to include throughout Poland (it is also available online). The inmates in local prisons. It continues to provide services publication, which has helped integrate medical and to IDUs and sex workers and to conduct educational policy professionals, lobbies consistently for new programs in local schools. The Gdansk city government approaches to drug addiction. and local health facilities have been supportive from the The Krakow Association of Assistance to Drug Users beginning. They have long been aware of the likelihood focuses its harm reduction efforts on two hard-to-reach that Gdansk would have one of the country’s largest populations: prisoners and sex workers. Overcrowding, drug-using populations, because it is Poland’s largest ill-trained personnel, and tough-on-crime politicians port and one of the gateways to Western Europe. combine to make conditions exceedingly grim for all prisoners, especially IDUs and sex workers. The project seeks to train prison staff about harm reduction strategies and to provide outreach to inmates in response to the growing problem of HIV and hepatitis infection. Commercial sex workers are the focus of the organization’s newest project. Many of them are unaware of the risks of HIV and hepatitis, and condom
50 IHRD usage is relatively low. The project holds educational TADA Harm Reduction Program workshops for sex workers, distributes harm reduction ul. Malkowskiego, No. 9/2 materials and information, and offers access to medical Szczecin 70305 treatment and counseling. Poland E-MAIL: [email protected] Nearly 40 percent of women IDUs in the region report MONAR Szczecin some history of sex work, making them more at risk for ul. Majkowskiego 9/2 contracting HIV or hepatitis than any other population. 70-305 Szczecin Expanding beyond its home base in Szczecin, TADA Poland provides comprehensive harm reduction services— E-MAIL: [email protected] including needle exchange and counseling—to sex A port city near the German border, Szczecin is a major workers throughout Poland. It supports teams of transit site for people and drugs trying to enter outreach workers in Warsaw, Poznan, Bialystock, Zielona European Union countries—legally and illegally. It has Gora, and Gdansk. TADA maintains close links with one of the country’s highest average percentages of drug other Polish NGOs working in the harm reduction field. users and sex workers. About 60 percent of the project’s clients have HIV and/or hepatitis B or C. The project cooperates closely Youth Counseling and Sex Education Unit with other local organizations for drug users, including Energetykow 2 those that offer counseling, methadone maintenance, 65001 Zielona Gora and basic medical services. Relations with local law Poland enforcement remain poor, however. Police officers have E-MAIL: [email protected] hassled outreach workers doing needle exchanges even Drug use in western Poland has increased rapidly in though such projects have the official support of local recent years, faster than anywhere else in the country. authorities. Many users, both male and female, turn to sex work to pay for their drugs, and few use condoms or other harm reduction strategies to reduce the risk of HIV, hepatitis, Social AIDS Committee and STDs. ul. Leszno 17 The project’s goal is to provide sex workers with the 01-199 Warsaw material and psychological tools to avoid taking risks Poland when using drugs or having sex. The main obstacles tend E-MAIL: [email protected] to come from the national government, reflecting the In addition to conducting direct harm reduction country’s conservative Catholicism, which is resistant to services, the project offers food packages, medication, the concept of harm reduction as a health policy. The and clothes to the more than 300 clients it serves each project is sometimes accused of existing solely to month—a number that currently stretches its resources provide drug users with the means to maintain their to the limit. It has developed close relationships with addictions. other organizations that provide free HIV and hepatitis testing and counseling services. Most clients now practice safer sex and safer injection practices. Many of them have taken the lead in educating their friends and providing secondary needle exchange with those who are unwilling or unable to contact the project themselves.
DIRECTORY 51 Romania General Directorate of Penitentiaries 47 Maria Ghiculeasa Street Adolescent Association Bucharest-2 8 Moise Nicoara Street Romania Bucharest 741391 E-MAIL: [email protected] Romania Romanian prisons are overcrowded and unsanitary— E-MAIL: [email protected] conditions that have contributed to a spread in hepatitis In Romania, public awareness of drug use is low, despite B and tuberculosis as well as HIV. The project, operated the fact that there is a sharply growing number of IDUs— by the government agency in charge of the penitentiary an estimated 5,000 in Bucharest alone. The majority of system, educates inmates and staff of Romanian prisons them are young people who start directly with heroin. on the risks of these diseases and provides harm The project operates both in Bucharest, the capital and reduction tips and strategies. It trains peer educators largest city, and in and around Constanta, a port city on and seeks to build positive links among staff, prisoners, the Black Sea that is the entry point into Europe for and the outside world, including inmates’ families and many illegal drugs. During holiday seasons, the project health care facilities. Discharged prisoners are offered extends its outreach program to Costinesti, a vacation free HIV testing and counseling referral. village popular with young people.
Romanian Association Against AIDS (ARAS) Alliance for Fighting Alcoholism and 23 Bdul Garii Obor, Apt. 8, Sect. 2 Addiction (ALIAT) Bucharest 72314 10 Berceni Street Romania Bucharest 75622 E-MAIL: [email protected] Romania The project, initiated in 1999, provides harm reduction E-MAIL: [email protected] services to sex workers in and around Bucharest. Among There are few services in Romania for drug users, the services offered are needle exchange, individual and although the government recently began offering group counseling, HIV testing, education, and referrals support for the development of new programs. ALIAT to health care facilities and other support organizations. has created a partnership with In-Dependent, a pilot ARAS is one of the oldest social service NGOs in program organized through the Ministry of Youth and Romania. It receives funding from a variety of Sport, to conduct peer and volunteer training, international organizations including UNAIDS and education, and counseling services for high-risk USAID. teenagers in three Bucharest high schools. It is also working with a different group to provide drug-use information for teenagers and their families in two other high schools. Some clients have taken the initiative to develop secondary needle exchanges with drug users who are reluctant or unable to contact the project.
52 IHRD Russia AIDS Center 50 Borisenko Street AIDS Center Vladivostok 690011 Gubkina Street, 48 Russia Belgorod 308036 E-MAIL: [email protected] Russia Drug use in the Russian Far East is double the rate of the E-MAIL: [email protected] country overall, primarily due to high unemployment, The Belgorod district sits along a major drug-transit government mismanagement of services, and route to and from nearby Ukraine and in recent years geographic and social isolation. Fewer than 100 IDUs the drug-using rate has risen sharply. Reported HIV have tested positive for HIV in the region, but the cases remain fairly low, but they are expected to surge number increases every year. as long as needle sharing remains fairly common. The project is the first to offer extensive harm Hepatitis infection is already a major problem reduction services in Vladivostok, the region’s largest among IDUs. city. Local branches of the Russian Ministry of Public The project offers consultations with medical Health and the Ministry of Internal Affairs have been personnel, safer drug use and safer sex information and quick to pledge their support materials, free condoms, and free testing for HIV and hepatitis. Its outreach efforts extend to two nearby towns, Razumnoe and Stary Oskol, which have high AIDS Infoshare numbers of IDUs. Bolotnikovskaa Street 1/2/84 Moscow 113556 Russia AIDS Center E-MAIL: [email protected] Minina Street, 20 Moscow has registered more than 15,000 cases of HIV, Nizhny Novgorod 603005 a growing number of them involving commercial sex Russia workers who are often drug users as well. The increasing E-MAIL: [email protected] possibility of contracting HIV or hepatitis is yet another With its harm reduction project serving some 500 burden placed on sex workers in the Russian capital, clients a month, the center estimates that it has reached where they are routinely harassed by police and a hostile about one-eighth the total number of IDUs in Nizhny general public. Novgorod and its suburbs. As the project continues to AIDS Infoshare has worked with sex workers since expand and work closely with similar local programs, the 1997. Its newest initiative targeting drug-using sex rate of HIV transmission has begun to drop. Local workers includes efforts to develop additional government and law enforcement agencies have been educational materials for clients and policymakers, mostly cooperative. The center has received support expand outreach efforts, and offer free medical from public health and narcological agencies as well as consultations. from Medecins Sans Frontieres.
DIRECTORY 53 “AIDS Stop” Foundation Anti-AIDS — South Lenina Street 46 119, Pereulok Gazetn Novorossiysk 353913 Rostov-na-Donu 344010 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] Before the project began in 1999, its organizers removed The project reaches about 16 percent of the local IDU all potential legal problems in discussions with local population directly; among these clients, needle sharing authorities. As a result, the project has the backing of has declined sharply in recent years. In addition to its the Novorossiysk government, police department, and own needle/syringe exchange center, the project education officials. It has also received favorable operates two satellite exchanges at local AIDS centers. treatment on local TV and in the main newspaper. One All offer a range of services from STI testing to reason for the high-profile support is that drug counseling. Project workers also organize educational trafficking is a quickly growing illegal industry in meetings with youth groups and with personnel of Novorossiysk, an important oil refining and export local prisons. center on the Black Sea . The environment for drug users in Rostov has The rate of HIV infection in the region has dropped improved due to increased awareness, but both the by some 150 percent since the project began. Most public and the authorities continue to view drug use as clients, who receive counseling and referrals in addition immoral. Most people still believe drug users could stop to harm reduction services, are young men in their 20s. using if they wanted to. Although the police do not The project also targets sex workers. interfere with the project, they have done little to help direct users to its services. Local drug treatment services are not free so few IDUs can afford them. Those who do Anti-AIDS participate find that their identities are not protected. ul. Voroshilova 18-70 Penza 440044 Russia Astrakhan Narcological Hospital E-MAIL: [email protected] Kotovskogo 6 More than 10,000 people in the Penza region are thought Astrakhan 414000 to be IDUs, and that number—and the HIV infection rate— Russia continues to rise. The project exchanges more than 8,000 E-MAIL: [email protected] syringes a week in an effort that seems to be making More than 500 IDUs use the project’s services each significant headway in changing behavior. According to month in Astrakhan, a Caspian Sea port close to both the the city’s narcological clinic, a growing number of IDUs Kazakh border and the turmoil in Chechnya. are now less likely to share works. The number of people Many clients report that they had felt completely seeking HIV tests at the local AIDS center has also risen isolated before the project was initiated and that this is sharply since the start of the project, which also conducts the first time they have been treated like “normal” outreach among sex workers. human beings—by people who care about their health Yet negative attitudes toward drug users persist. and future. The project tries to counter these attitudes by teaching The project maintains good working relationships that drug users have serious addiction diseases and are with other public health services and organizations. not necessarily criminals. The police and local However, despite a letter of support from the head of the government have been cooperative, and about 70 Drug Enforcement Department, lower-level officials percent of the general population supports the concept from that agency continue to have a negative attitude of harm reduction. toward harm reduction.
54 IHRD Charity Foundation “No to AIDS Engels Health Department and Drugs” 30 Lenin Street Kopernika Street 2/4 Engels 413100 Kaliningrad Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] Although directly across the Volga River from the much The Kaliningrad region, separated from the rest of larger city of Saratov, Engels is nevertheless an Russia and nestled between Lithuania and Poland, has important transit site for drug trafficking. An estimated perhaps the country’s most severe HIV problem. 5,000 IDUs live in Engels, up sharply in recent years. Officially nearly 3,000 people have tested positive for City officials moved to establish the harm reduction HIV, of whom at least 60 percent are IDUs. Other project when the number of IDUs who tested positive ominous health problems among the region’s more for HIV rose from 0 to 72 in just one year, from 1998 than 15,000 IDUs are hepatitis C (30 percent thought to 1999. to be infected), hepatitis B (40 percent), and syphilis One of the project’s main goals is to change public (50 percent). opinion, which currently considers drug users criminals The project relies heavily on its mobile needle who should automatically be thrown in prison. The exchange unit, especially in its efforts to reach nearby project is also collaborating with other government Romani villages where residents largely shy away from agencies and some NGOs in an effort to increase existing health care facilities. Drug use is increasing at a psychological and medical services for clients. disproportionately high rate among the Roma, who already are the area’s poorest and most marginalized community. Forpost Center Uralskikh rabochikh, 50B Ekaterinburg 620042 District Center for the Battle against AIDS Russia Prospect 50 Let Oktiabria, Bldg. 2, Block 2 E-MAIL: [email protected] Tver 170024 Ekaterinburg, formerly Sverdlovsk, is known throughout Russia the world as the city where Tsar Nicholas II and his E-MAIL: [email protected] family were killed 80 years ago and, more recently, as More than 1,000 IDUs in the Tver region are now the power base of former President Boris Yeltsin. It is infected with HIV, a number that represents at least 85 one of the largest cities in the Ural Mountains region, percent of all reported cases. An even greater number of long considered Russia’s frontier, and over the past few drug users have hepatitis B and/or hepatitis C. The years it has borne the brunt of much of the increase in project’s goal is to hold these numbers stable by drug use in the area. providing IDUs with safer drug use information and Forpost’s harm reduction project has had great materials, such as clean needles and disinfectant, and success in setting up an extensive outreach network that safer sex services, including condoms. enables workers to visit IDUs at their homes or in The project has formed close relationships with nearby shooting galleries if clients are unable to come the local Department of Health Services, Department of to its center. Among the services available are Education, and District Narcotics Dispensary. It has needle/syringe exchange, free legal advice, and referral made a strong effort to spread the prevention/education to health care specialists. message through regular contacts with the local media.
DIRECTORY 55 Garmonia Kuzbass Anti-AIDS 32-a Geroev Prospect Kemerovo Balakovo 413800 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] The administrative center of the Kuzbass region some A sharp increase in drug use was first noted in Balakovo, 3,500 kilometers from Moscow, Kemerovo is a relatively a city in the Saratov region, in the mid-1990s. Today, new city, having been founded during World War II when more than 12,000 of the city’s 200,000 residents are Soviet planners established industrial cities far from the thought to be IDUs, and an increasingly higher Western front. Today its half a million residents face percentage of them are testing positive for HIV. increasing poverty as the country’s huge industrial The project’s main goal is to reduce risk behavior complexes struggle to be economically viable. among IDUs and those infected with HIV by a factor of As living standards have declined, drug use has 30 percent each year. It also focuses on improving public risen. The project seeks to halt the spread of HIV, opinion toward people in those categories and toward hepatitis, and other blood-borne diseases by building a sex workers, an at-risk group it began targeting recently. comprehensive outreach network to bring IDUs and other at-risk populations to its needle exchange center for HIV prevention information and materials. Health Department of Sakhalin Regional authorities have helped arrange referral Regional Administration services, including health care, for clients. 53A Amurskaya Street Yuzhno-Sakhalinsk 693000 Russia Marya E-MAIL: [email protected] Kozlovskaya Street, 10 Although poor and isolated on Sakhalin Island off Volgograd 400001 Russia’s Pacific Coast, Yuzhno-Sakhalinsk has not Russia escaped the surge of drug use that began in the late E-MAIL: [email protected] 1990s. One of the project’s main successes has been The project appears to have made a significant impact, calling government and media attention to the problem largely because many IDUs in the region have learned to of drug use in the region and the benefits of harm reduce risky behavior and practice safer sex. According reduction programs. Authorities have pledged to help to Marya, there have been no new cases of hepatitis B or fund additional, similar projects in the future. C infection registered in the city since the beginning of The project is the only specialized service for drug 2000. In 1998, some 76 percent of IDUs were sharing users in the city besides a local hospital’s narcology unit. syringes and needles; today, that number has dropped to In addition to identifying needy clients and conducting 30 percent. The percentage of IDUs who say they now needle exchange, it publishes and circulates pamphlets practice safer sex has doubled, to 67 percent. The and information on safer sex and the psychological project serves about 900 clients a month but expects effects of drug use and addiction. that number to rise rapidly as its mobile units expand services to remote areas. A growing number of clients are sex workers. Although there are legal restrictions on drug use and treatment, local authorities have supported the project’s outreach efforts. Volgograd has eight medical clinics that offer drug treatment as well as a rehab center targeted to the newly addicted.
56 IHRD Ministry of Health of the Kalmyk Republic NGO Humanitarian Project 3 Mikro rayon, 23-47 Nivhegorodskaya Street, 27-8 Elista 358009 Novosibirsk 630009 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] Before project workers began making direct contact with The majority of clients served regularly by the project in IDUs, the police would bring clients in after making Siberia’s most populous city are younger than 20. They spot-checks of local shooting galleries. Relations with are disenchanted with high unemployment, sinking the police remain good, and local officials from the living standards, and a harsh climate. The project offers Ministries of Health, Interior, and Youth Affairs support them standard harm reduction services as well as the project. The number of IDUs using the project’s medical and psychological counseling and prevention services continues to increase, as does the level of trust education. they have in its workers. The project has begun The project has established links with an AIDS conducting educational programs through the media and center and some local drug clinics. It is also a member of in local schools. Russia-Ukraine AIDS Infonet, a network of AIDS prevention organizations, including those in 10 nearby cities and towns. Narcological Hospital Lesnai Street, 2 Saransk 430030 NGO Pervouralsk Without Drugs Russia Vatutina, 10/26 E-MAIL: [email protected] Pervouralsk 623100 The number of IDUs in the Republic of Mordovia, of Russia which Saransk is the capital, is low compared with the E-MAIL: [email protected] rest of Russia. The project’s main goals are to maintain The NGO has two projects currently operating, one that distinction by educating young people about the targeting IDUs and the other sex workers. risks of drug use and to provide IDUs with harm Nearly all IDU clients report having shared reduction services to prevent the possible spread of injecting equipment, and some 58 percent say they do hepatitis and HIV. not always use condoms. Thus, the focus has been on expanding prevention education. The IDU project has established links with similar projects in other cities as well as medical and social service agencies elsewhere in Russia and abroad. In cooperation with the Health Administration, the AIDS Center, and the Narcological Service, the project hosts educational training seminars for medical professionals and other specialists. The sex-worker initiative aims to have at least 200 people engaged in its harm reduction services by the end of 2001. It provides one-on-one and group counseling and offers extensive referral options.
DIRECTORY 57 North — Stop AIDS Pskovian Anti-AIDS Initiative Shchetinina Street, 17A Igorskogo Bataliona Street 10 Vologda 160002 Pskov 180020 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] One of the most ancient cities in Russia, Vologda is now The organization runs two projects, a needle exchange struggling with some of the country’s newest problems, program (NEP) and a prison program. The NEP offers a including increased drug use and its related social ills. wide range of services to its clients, ranging from HIV and The project has secured the support of local authorities hepatitis testing to medical and dental assistance. It has as it seeks to limit the spread of HIV and hepatitis also moved toward providing counseling and information through a center providing needle exchange, referral to the sexual partners and families of clients. services, and HIV testing. The next step is to build an Although HIV is spreading rapidly in other cities in extensive education outreach system for IDUs and the region, notably St. Petersburg, no clients have tested others at risk, including sexually active young people. positive for the virus in Pskov. Nearly half of them, however, are infected with hepatitis C, and about 11 percent have hepatitis B. Local authorities have shown Parents Against Drugs support for the initiative. Some police officers have 2 Tukhachevskogo directed IDUs to the project instead of arresting them Toliatti 445002 for using illegal drugs. Russia The HIV Prevention in Prisons project conducts E-MAIL: [email protected] outreach work among the incarcerated in the Pskov Relative to much of the rest of Russia, wages are high and region. Prisoners are given access to condoms and unemployment low in Toliatti, a center of the country’s disinfectants, for example, and can receive automobile and chemical industries. Drug use, however, psychological support from workers and volunteers is rising as rapidly as in other comparably sized cities. trained in harm reduction strategies. The project holds regular informational seminars on HIV prevention and harm reduction techniques with city officials, employees of the giant auto factories, the Regional AIDS Center mass media, and the general public. Local rehab clinics 20 Chumbarov-Luckinsky Ave. and government health care and drug authorities are on Arkhangelsk 163061 board as enthusiastic supporters of the project. Russia E-MAIL: [email protected] Nearly 10,000 drug users live in and near Archangelsk, a major port on the White Sea in northern Russia. Over the past few years heroin has quickly become one of the most popular drugs in the region, and most users prefer to inject it. Local authorities are supportive of the project’s harm reduction efforts. HIV infection rates have increased steadily, but the major short-term problem has been the high hepatitis rates among IDUs. The project plans to expand its outreach efforts to reach large satellite cities, including Sverodvinsk and Novodvinsk.
58 IHRD Regional AIDS Center Regional Branch of NAN Gagarina Street 135 46 Kuibyshev Street Lipetsk 398043 Perm 814039 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] For the most part, authorities in Lipetsk have cooperated Situated in the Ural Mountains where Europe and Asia with the project, which operates standard harm meet, Perm is a major industrial city of more than one reduction services such as needle/syringe exchange as million people. Drug use has become increasingly well as HIV testing and referrals. Project managers hope widespread in recent years, with more than 15,000 IDUs to expand their outreach efforts by recruiting more now estimated to live in the city. The potential for the former and current IDUs as volunteers. spread of HIV is quite high because needle sharing remains common and IDUs make up the largest percentage of those with HIV in the region. Local Regional AIDS Center authorities have expressed support for the project, Lenina Street, 434 which seeks to expand its outreach and education efforts Stavropol 355029 to reach additional at-risk populations. Russia E-MAIL: [email protected] The civil war in Chechnya and other ethnic strife have Regional Family and Children Social destabilized the Caucasus region, leading to a rise in Aid Center drug smuggling through many of the cities. Stavropol is 27 Pugacheva Street no exception. The city of 350,000 people is experiencing Samara 443077 an increase in drug-related crime and drug use by a Russia growing number of its residents. The project’s clients E-MAIL: [email protected] receive free, anonymous HIV testing, needle/syringe Besides IDUs and people with HIV, the project targets exchange, and access to extensive counseling services. many of its harm reduction efforts at drug users’ Clients are encouraged to refer others to the project. families and friends, who often need counseling and other support services, and teenagers in general, who are most at risk for acquiring a drug habit or potentially Regional AIDS Center fatal disease. Several local government agencies and Kirova Street 3-23 NGOs support the project, often providing referral Voronezh 394018 information and additional outreach help. Russia E-MAIL: [email protected] An historic inland port on the Voronezh River near the Ukraine border, Voronezh sits on a major drug-transit route. It faces burgeoning social problems associated with drug use, including a rise in cases of hepatitis and STIs and the first cases of HIV infection in the region. The project offers HIV testing and referrals to health care and counseling services. Its outreach efforts focus on the more isolated parts of the city where the poorest, least educated IDUs live.
DIRECTORY 59 Republican Center for Russian Society Charitable Fund Prevention and Fight Against AIDS Registration Room 53, Administrative Building, and Infectious Diseases SibNIISHhoz 17 Tsyvilieva Street Koroleva Street Ulan-Ude 670034 Omsk 644012 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] The Republic of Buryatia, of which Ulan-Ude is the Although HIV infection is a growing problem in Omsk, capital and largest city, has been hit especially hard by the biggest immediate concern is hepatitis. More than the recent increase in drug use in Russia. The hepatitis three-quarters of IDUs who share works are infected infection rate among the general population is twice with that blood-borne disease, and many are unaware that of the national average, and the syphilis rate is not that sharing greatly increases transmission risks. far behind. The project holds training seminars for other social The lack of adequate financial resources has service agencies and government officials in the region. restricted the ability of the local Ministry of Health and Its outreach program is staffed primarily by former other government agencies to take aggressive measures IDUs, some of whom are helping establish contacts with to combat the spread of HIV and hepatitis. As a result, media outlets in an effort to promote the concept of they have been extremely supportive of the project from harm reduction. the beginning.
Siberian Initiative Russian Charity Foundation, P.O. Box 783 “No to Drugs and Alcohol” Barnaul 656054 33 Serysheva Street Russia Khabarovsk 680038 E-MAIL: [email protected] Russia The project is the first in this city on the Ob River in E-MAIL: [email protected] Siberia to focus specifically on drug users and harm The Khabarovsk region’s unemployment rate remains reduction strategies. Although local authorities were persistently high, and public health conditions have originally wary of the project’s approach, they have declined in recent years. There are thought to be about become more supportive as the number of people with 30,000 IDUs in the Khabarovsk region, which has a HIV has increased, threatening to become a major population of about 1.5 million—one of the highest rates public health crisis. in the country. Because there are no central areas where drug users Although local authorities continue to strictly meet, the project must concentrate its outreach efforts enforce drug laws and policies, they have started to on users’ apartments and places of work. To increase recognize the severity of the drug problem and the need confidence among clients, the project hopes that the for new approaches. The regional administration has majority of its outreach workers will eventually be given its support to the project, as have local radio and former or current IDUs. TV stations, many of which have aired programs about drug use. The project has succeeded in increasing awareness about HIV and other risks of needle sharing. Its clients are 20 percent less likely to share needles than those who have never used its services.
60 IHRD Tatarstan Ministry of Public Health We Are Against AIDS 2a Vishnevskogo Street Karl Marks Street, 45 p/o 25535 Kazan 420097 Krasnoyarsk 660000 Russia Russia E-MAIL: [email protected] E-MAIL: [email protected] Even though the project has the strong support of the As a result of the organization’s efforts, Krasnoyarsk’s Tatarstan Ministry of Internal Affairs, many IDUs are drug enforcement agency and police department have afraid of police harassment and remain difficult to agreed not to interfere with its harm reduction work. reach, even when they need urgent medical attention. The local media regularly publicizes the project and Still, the project, which also focuses on sex workers, helps spread awareness. has been successful in helping clients modify their The project’s mobile unit conducts needle exchange behavior and adopt safer drug use techniques. As a throughout the city and has relationships with 10 clinics, result, the number of new cases of HIV infection among including narcological centers and hospitals where its clients is much lower than among IDUs not infectious diseases are commonly treated. More than 40 connected with the project. Regular project clients percent of the project’s clients, including many sex consider it the only program that treats them humanely. workers, use its services regularly. Much of the outreach is conducted by volunteers, The project’s goals include decreasing IDU risk including former and current IDUs. behavior from 69 percent to 50 percent over the next year; encouraging IDUs who have only basic education to use the services regularly; and providing comprehensive Vozrastcheniye Foundation harm reduction education to a minimum of 80 percent Sredniy pr. V.O., 65/41, Room 31 of clients. St. Petersburg 199178 Russia E-MAIL: [email protected] Youth Center for Change The project serves IDUs and sex workers in the St. Voronova Street, 11 Petersburg district of Kolpino. Since it started, the Verkhnya Salda 624600 number of HIV infections has remained steady, while in Russia St. Petersburg overall the infection rate has continued to E-MAIL: [email protected] grow sharply. Hepatitis remains a serious problem, Through seminars and education outreach, the project however: nearly 70 percent of clients are infected with has made great strides in reducing the stigmatization of hepatitis C. About 1,200 clients, many under 20 years drug users. Government agencies, including health care old, are served per month. In addition to its facilities, now largely support harm reduction strategies. needle/syringe exchange services, the project holds Needle/syringe exchange remains the centerpiece of the seminars on HIV/AIDS prevention for local college and project’s efforts. It also offers counseling on risk high school students. avoidance and referrals for serious medical and Most IDUs do not trust the state Narcology Service psychological issues. and prefer to seek help and services, including basic medical attention, at the project’s center. Some other organizations have directed drug users to the foundation and helped provide medical, psychological, and social support services for its clients.
DIRECTORY 61 Slovakia Slovenia
Heureka AIDS Foundation Robert/Stigma Dolna Strieborna 2 Wolfova 8 Banska Bystrica 97401 Ljubljana 1000 Slovakia Slovenia E-MAIL: [email protected] E-MAIL: [email protected] Banska Bystrica is one of the largest cities in central Harm reduction is one of the national AIDS program’s Slovakia, with nearly 100,000 people and an estimated priorities, but government financial support is scarce 1,200 drug users. During a previous pilot program, and drug laws present obstacles. Needle exchange project workers reported that at least 90 percent of IDUs programs (NEPs) are legal in Slovenia, although safer were reusing works. Although HIV has not made major “injecting rooms” are not; using drugs is not prohibited, inroads in the city, at least 60 percent of IDUs are but possession is illegal. A network of 15 methadone thought to be infected with hepatitis C. maintenance centers is spread throughout the country, The project, which operates two centers, seeks to and there is one detox center in Ljubljana. expand its outreach to the so-called hidden drug users— The foundation operates a needle exchange those who refuse the help of social service organizations. program called Stigma and a separate harm reduction Most are young, poor, and, having been harassed by the project focusing on Slovenian prisons.The NEP serves police, suspicious of any form of authority. some 1,000 clients a month. More than 60 percent of the clients are infected with hepatitis C, but the HIV rate is low. Counseling is available on social, health, legal, Odyseus and housing issues. The project has taken the lead in Ukrajinska 10 educating the general public about drugs, safer sex, and Bratislava 83102 the benefits of HIV and hepatitis testing for those at Slovakia risk. It has also undertaken research on the behavior, E-MAIL: [email protected] trends, and culture of IDUs. The project, opened in October 1998, was the first harm The prison project provides the most at-risk reduction program of its kind in Slovakia, where drug inmates, including IDUs and men who have sex with laws are relatively harsh. Although punishment for men, with access to needle/syringe exchange, condoms, dealers tends to be particularly severe, even users and counseling services. carrying small amounts face big penalties if apprehended. As a result, most drug users are afraid of having a syringe or any other part of their works with them on the street. Nearly 500 clients are served each month; some 60 percent of clients are women, mostly sex workers. Drug- using clients are offered standard needle exchange and safer sex information as well as contacts with public health care and social services. Other organizations working with drug users and sex workers report that, due to the project’s efforts, knowledge about safer behavior and better health habits has increased rapidly.
62 IHRD Tajikistan Volunteer Association 24 Lenina Street, Suite 11 Health, Rights and Society NGO Khorog 736000 12 Microrayon 14, Flat 128 Tajikistan Khujand 7357000 E-MAIL: [email protected] Tajikistan The association’s mission is to reduce drug use and its E-MAIL: [email protected] associated harms. In the past few years, the association In addition to harm reduction, the organization runs has opened a rehabilitation center and conducted health promotion and anti-illiteracy campaigns among several education campaigns in area schools and in the local youth. Local health authorities support the harm media. The harm reduction project works closely with reduction program, with the City Clinic allocating rent- the association’s other initiatives, in particular its free space for a permanent needle exchange and outreach programs. It has implemented the first information center. comprehensive effort to collect and analyze data on IDUs One of the biggest hurdles facing the project is and HIV and hepatitis incidence among them. overcoming the reluctance of drug users to jeopardize their anonymity by interacting with harm reduction personnel. In the past, this has left many of them lacking essential medical services. No cases of HIV have been recorded in the Khujand region, but increasing migration to the city from rural and war-torn areas in the south is expected to lead to a rise in blood-borne diseases within the IDU community.
Run NGO Head Post Office, Mailbox 50 Dushanbe 734000 Tajikistan E-MAIL: [email protected] Tajikistan shares a long and often unguarded border with Afghanistan, a strife-filled country that is the world’s largest producer of opium poppies. Shipments of opium derivatives such as heroin pass through Tajikistan on their way to Western Europe. This surging drug trade has led to a rise in illegal drug use across the country. Dushanbe, the capital and largest city, has the largest number of IDUs, most of them young, poor, and unemployed. The project’s harm reduction strategies are aimed at restraining the growth of HIV and hepatitis among that population. It also seeks to educate government officials—in particular those with a reflexively restrictive attitude toward drug use—about the drug problem and the benefits of harm reduction.
DIRECTORY 63 Turkmenistan Ukraine
Annageldy “All Together” Information Center 51 Gorogly Street Shevchenko Street, 32/11 Ashgabat, Turkmenistan 744012 Lviv 79016 E-MAIL: [email protected] Ukraine Turkmenistan has one of the world’s lowest HIV rates. E-MAIL: [email protected] However, sharp rises in the rates of syphilis and In its first year, the project added clients at a rate of gonorrhea have increased the risk of an increase in HIV 30-35 a month in Lviv, the largest city in western prevalence. To lower the risk, the project is providing Ukraine and one of the hardest hit by the twin HIV and condoms and prevention information to sex workers. drug use epidemics. There are few state-run facilities The project also provides access to better-quality for drug users in Lviv, so All Together is the only medical care and rehabilitation services for drug-using consistent source for information, support, and medical sex workers. It is training an advocacy team to expand referrals, in addition to needle exchange. prevention activities at summer resorts and hopes to Volunteers, including former and current IDUs, develop pilot programs in other cities. conduct much of the outreach effort. The project focuses on establishing trusting relationships with clients in order to expand word-of-mouth referrals as well. Force for Change The most recent extensive outreach effort is aimed at 51 Gorogly Street sex workers. Ashgabat 744012 Turkmenistan E-MAIL: [email protected] Association “Victoria” Force for Change is an NGO working in cooperation with Shevchenko Street, 34 Turkmenistan’s National AIDS Prevention Center. Its Khmelnitskiy 29000 prison project aims to prevent HIV infection and reduce Ukraine drug use among prisoners in two correctional facilities E-MAIL: [email protected] by offering direct access to disinfectants and other harm Drug use has become a huge social and economic reduction services as well as promoting healthier problem. It is estimated that one of every three families lifestyles in general. It has conducted training either has a member who uses drugs regularly or knows workshops for prisoners and prison staff and begun to one well. Local authorities are supportive of the harm build a group of peer leaders to work with project staff. reduction project but unable to provide much financial assistance. The association also operates a rehabilitation center organized with substantial help from similar organizations in neighboring Poland. It plans to expand that model elsewhere in Ukraine.
64 IHRD Charitable Anti-AIDS Foundation Charity Foundation “Blagodijnist” 55 Tsyolkovsky Street, Apt. 97 Nikolskaya Street, 17, Apt. 16 Poltava 36023 Nikolaev 54030 Ukraine Ukraine E-MAIL: [email protected] E-MAIL: [email protected] Since the project was initiated in 1997, the foundation Blagodijnist runs a needle exchange project (NEP) and has become a leader in the field of harm reduction in a separate prison-focused harm reduction project. Ukraine. Its activities range from service provision and The NEP serves more than 4,400 clients a month, outreach to IDUs and sex workers to counseling and dispensing some 25,000 syringes. Much of its outreach advocacy for people living with HIV and AIDS. Nearly effort is conducted by volunteers, many of whom are 1,000 people in the region are officially registered as HIV positive IDUs. About two-thirds of the project’s being infected with HIV, although the true number is clients are male, but that ratio is likely to change as the likely to be much higher. project reaches out to sex workers. In addition to needle Local public opinion and awareness regarding drug exchange, the project distributes condoms and use and HIV/AIDS have improved significantly due to information on safer injecting and safer sex practices. the project’s work with clients, their families, and the The prison project offers needle/syringe exchange press. A wide range of infomation and training materials and condoms to inmates in a large local penitentiary. It is available at the project’s stationary and mobile has set up “trust” stations to handle the distribution of exchanges. The foundation’s website also contains these items, and has implemented a system to track the useful and country-specific harm reduction number of syringes entering and leaving the prison as information. In 2000, the foundation provided technical well as their movement within. assistance to 14 harm reduction projects in Ukraine. Blagodijnist works closely with local government, law enforcement, and social service agencies as well as with the media, and has established relationships with a variety of harm reduction projects in Ukraine and other Eastern European nations.
DIRECTORY 65 Charity Fund “The Way Home” Charity Fund “Unitus” Bolshaya Arnautskaya Street 42 Novobugskaya 101, kv. 46 P.O. Box 25 Nikolaev 54031 Odessa 65011 Ukraine Ukraine E-MAIL: [email protected] E-MAIL: [email protected] Falling living standards and the removal of travel More than 20,000 drug users live in Odessa, an restrictions have contributed to a steep increase in important Black Sea port that is a magnet for drug the number of sex workers in Ukraine and other dealers and users from nearby Turkey, Romania, and countries of the former Soviet Union. While many end Moldova. The number of people infected with HIV, up working in Western Europe—after either heading estimated at 13,000, has exploded in just a few there themselves or being forcibly transported by short years. organized crime members or other exploiters—others The project serves more than 10,000 clients, have congregated in towns such as Nikolaev in western including sex workers, per month. According to staff, Ukraine, near the border with Poland and other richer the constant increase in the number of clients proves nations. that the project’s services are badly needed and its Unitus’ project offers sex workers in several local strategies for gaining the trust of clients have been towns a full range of harm reduction services, including successful. In particular, they point to its mobile unit, essential health care information, STI prevention which moves among drug-buying and -using areas and education, and needle/syringe exchange when refers IDUs to its stationary office. requested. Its outreach efforts rely in part on clients’ The project, made possible through national referrals, a strategy that helps overcome suspicion and legislation and local government directives, enjoys fear of harassment or arrest by local authorities. widespread support among state health and law enforcement authorities. It seeks to share information and resources with similar projects elsewhere in the Cherkasy Regional Narcology Dispensary country as well as with social service agencies in Nechuy-Levitskij. 22 Odessa itself. Cherkasy 18018 Ukraine E-MAIL: [email protected] The IDU population in Cherkasy is growing at a rate of 10 percent a year, and nearly 1,000 people are officially registered as having HIV—a number that in reality is thought to be much higher. The project has strong support from the media, and relations with the police are satisfactory. A state-run regional HIV prevention program is not considered particularly effective due to lack of adequate financing. In addition to needle exchange and basic information on harm reduction, the project provides psychological, medical, and spiritual support for its clients. It has cooperated with a variety of social services, including one run out of a local hospital by the Orthodox Church.
66 IHRD Donetsk Regional HIV-Infected Assistance Kryvy Rig Center for AIDS Prevention Association 4 Nikopilske Shose Olimpieva Street, 1-A Kryvy Rig Donetsk 83045 Ukraine Ukraine E-MAIL: [email protected] E-MAIL: [email protected] The AIDS epidemic hit Kryvy Rig with full force in the Located in the heart of Ukraine’s coal-producing region, mid-1990s. Since then, some 4,000 people in the which now has some of the worst economic conditions in region have been officially registered as having HIV— the former Soviet Union, the project serves some 2,000 more than 90 percent of them are IDUs, most of whom clients each month. Before the project started, most have long shared needles and had unprotected sex. clients were unaware of the risks of HIV and hepatitis Several local government agencies and NGOs are infection; in 1999, an estimated 85 percent of the IDU involved with the project’s harm reduction efforts, population was infected with HIV. including groups that serve teenagers and adolescents. As the number of clients continues to increase, so The project works to expand awareness of HIV and drug does demand for its counseling and training programs. use through public forums and the media. Those initiatives are believed to have played a role in a recent decline in the HIV infection rate among clients, their spouses, and their children. The project has also Organization Salvation made strong strides in reaching at-risk sex workers. 7th Khorolski Tupick, 2-a The project cooperates with most Donetsk social Kremenchuk 39603 service agencies, public foundations, and similar Ukraine organizations. It has formed a close link to a local youth E-MAIL: [email protected] outreach group, VISSON, referring 50 clients to the The project’s stationary and mobile centers are group’s rehabilitation center. The radio station “Europe considered a trusted source of information and services Plus” has also agreed to publish a book written by clients by IDUs and sex workers. The number of IDU clients as part of an education and prevention effort. who report regularly using condoms has increased greatly, and most sex workers say that they now have sex only with condoms and get checkups regularly at local STI clinics. The organization has recently opened a counseling center for IDUs and their families. Organization Salvation shares experience and information with workers and volunteers at similar projects in other Ukrainian cities, including Kiev, Kharkov, Donetsk, and Poltava.
DIRECTORY 67 Society for Civic Self-Advocacy Regional AIDS Center 32/51 Svobody Street 179 Kirova Street Uzhgorod 88000 Sumy 244021 Ukraine Ukraine E-MAIL: [email protected] E-MAIL: [email protected] Located in far western Ukraine near the Slovak, The center’s project, known as “Step Forward,” serves Hungarian, Polish, and Romanian borders, Uzhgorod is IDUs in the area’s two largest cities, Sumy and Shostka. an ethnically diverse city that now serves as a center for The number of drug users in those towns now exceeds goods—including illegal drugs—moving between Western 10,000. Although few clients have tested positive for Europe and the former Soviet Union. Steeply rising HIV, more extensive testing and outreach efforts are numbers of IDUs and people infected with HIV have expected to lead to an increase. A typical client today is been most prevalent in the large Romani community, an unemployed injecting drug user with few solid family which has generally shunned local health facilities. ties or responsibilities. The project focuses directly on the Roma, holding Regional authorities have helped the project educational seminars for community leaders as part of establish links with local youth and drug-use an effort to allay suspicions and encourage IDUs to organizations in order to share resources and strategies. participate. It also works as a liaison between the Roma The project has also been active in organizing and and Ukrainian health authorities. participating in regional and international conferences and seminars.
Red Ribbon 6 Borby Street Regional SALUS Foundation Kharkov 61044 Technichna Street 6/8 Ukraine Lviv 79000 E-MAIL: [email protected] Ukraine When the project began in September 1999, there was a E-MAIL: [email protected] low level of awareness about HIV transmission and SALUS has worked with commercial sex workers for prevention among IDUs and sex workers; the latter were several years in Lviv and other Ukrainian cities. Its new particularly vulnerable because of male partners’ harm reduction project focuses on the growing unwillingness to use condoms.The project has worked percentage of sex workers in Lviv who are also IDUs. hard to tackle these problems. The number of IDUs who According to recent SALUS surveys, a majority of sex use its services—which include medical, social, and workers in the city have little knowledge of HIV and psychological assistance—increased 20-fold in the first other STIs—and they generally work without condoms. nine months, while the number of sex workers who Sex workers who inject drugs frequently share needles became clients increased five-fold, trends that have and do not get regular medical treatment. continued. The project also seeks to educate the public about HIV and those most at risk.
68 IHRD Vinnitsa Public Congress “Stalist” Uzbekistan P.O. Box 7385 Keletskaya Street Tashkent City Women’s and Children’s Vinnitsa 21029 Center (SABO) Ukraine Adbullaeva Street 49/50 E-MAIL: [email protected] Tashkent 700052 The project serves more than 3,400 clients a month, yet Uzbekistan the number requesting services continues to increase. E-MAIL: [email protected] An estimated 60 percent of IDUs in Vinnitsa have been Ignorance of the risks of HIV and other STIs is relatively reached by the project on some level, which has helped high in Uzbekistan. Those at greatest risk—commercial keep the rate of HIV prevalence relatively low. The sex workers—are not necessarily better informed than police and local authorities in Vinnitsa have cooperated the general public. Surveys indicate that few of the fully with Stalist’s harm reduction program, which is estimated 5,000 sex workers in Tashkent have ever had made easier by the fact that Ukrainian law does not an HIV test even after other STIs have been confirmed. prohibit needle and syringe exchanges. The project is increasing AIDS education efforts, in The project, which also serves sex workers, has particular among sex workers who use drugs, with the expanded some of its services into other towns in the help of new volunteers and specialized prevention Vinnitsa region, including Kalinovka, Tyvrov, and information. It is setting up a hotline and new condom- Nimirov. With the assistance of government drug distribution centers throughout the city. authorities, Stalist is trying to organize needle exchange programs in the southern part of the region where drug use and AIDS are more widespread.
Zhitomir Regional Charitable Foundation 18/26 Polskiy Bulvar, k. 80 Zhitomir 10020 Ukraine E-MAIL: [email protected] The Zhitomir region is a major drug trafficking center, with excellent agricultural conditions for cultivating narcotic plants. The project’s work is part of the regional government’s AIDS prevention initiative, and several government officials are involved in determining priorities, which include creating an atmosphere of tolerance regarding drug users. In addition to needle exchange and condom distribution, the project conducts educational programs for IDUs, and offers them medical, legal, and psychological help as well as free HIV testing and counseling. Among the organizations affiliated with the center are UNAIDS, Medecins Sans Frontieres, and the Red Cross.
DIRECTORY 69 Injecting drug users are widely scorned and frequently neglected or subjected to punitive treatment. Harm reduction programs, however, believe that the well-being of everyone matters—as individuals and as members of society.
70 71 NOTES
1 Dehne, K.L., Kobyschcha, Y., The HIV Epidemic in Central and Moving beyond the Controversy, Washington, DC: U.S. Conference of Eastern Europe: Update 2000, 29 November 2000. Mayors; 1997. American Medical Association 6/97 Statement on 2 UNAIDS Epidemic Update, December 1999. Syringe Exchange. Lurie, P., Reingold, A., The Public Health Impact 3 Report of the Secretary-General, Special session of the UN of Needle Exchange Programs in the United States and Abroad General Assembly on HIV/AIDS, 16 February 2001. (prepared for the Centers for Disease Control and Prevention), 4 Moulson, Geir, “U.N. warns of AIDS complacency, says epidemic Berkeley, CA: University of California, School of Public Health, explodes in Russia,” Associated Press, 28 November 2000. and San Francisco, CA: University of California, Institute of 5 Ibid. Health Policy Studies, 1993. Normand, J., Vlahov, D., Moses, L.E., 6 “Svodki s epidemicheskogo front” (“News from the Epidemiological eds. Preventing HIV Transmission: The Role of Sterile Needles and Front"), issue 325, 10 April 2001. http://www.medportal.dn.ua/sef/ Bleach, Washington, DC: National Academy Press, 1995. National 7 Second Strategy Meeting to Better Coordinate Regional Support to Commission on Acquired Immune Deficiency Syndrome, The Twin National Responses to HIV/AIDS in Central and Eastern Europe Epidemics of Substance Use and HIV, Washington, DC: National and Central Asia, Copenhagen, Denmark, 4-5 December 2000. Commission on Acquired Immune Deficiency Syndrome, 1991. 8 Rhodes, T., Ball, A., Fitch, C., Stomson, G.V., Kobyshcha, Y., National Institutes of Health Consensus Panel, Interventions to Prokovski, V., Burrows, D., Berzuchenko-Novachuk, M., and Prevent HIV Risk Behaviors, Washington, DC: National Institutes of Andrushchak, L., “The rapid spread of HIV among injecting drug Health, 1997. users in Eastern Europe demands rapid assessment and 28 See, among others: Normand, J., Vlahov, D., Moses, L.E., eds., response,” Addiction 94: 1323-36, 1999. Preventing HIV Transmission: The Role of Sterile Needles and Bleach, 9 UNAIDS Epidemic Update June 2000. Washington, DC: National Academy Press; 1995:224-226, 248- 10 “The Determinants of the HIV/AIDS Epidemic in Eastern 250. Paone, D., Des Jarlais, D.C., Gangloff, R., Milliken, J., Europe,” Geneva, Switzerland, 28 June – 3 July 1998. Friedman, S.R., “Syringe Exchange: HIV prevention, key findings 11 “Education for HIV Prevention in Prisons,” a proposal submitted and future directions,” International Journal of the Addictions, to IHRD by the General Directorate of Penitentiaries, Romania, 1995;30:1647-1683. Watters, J.K., Estilo, M.J., Clark, G.L., 2000. Lorvick, J., “Syringe and Needle exchange as HIV/AIDS 12 Stern, Vivien, A Sin Against the Future: Imprisonment in the World, prevention for injection drug users,” JAMA 1994:271:115-120. Penguin Group, 1998, p. 75. Office of Technology Assessment, The Effectiveness of AIDS 13 Health Promotion Program in the Russian Prison System: Prisoner Prevention Efforts, Washington, DC: Office of Technology Survey 2000, Medecins Sans Frontieres – Holland, November, Assessment, 1995. Stimson, G.V., Alldritt, L.J., Dolan, K.A., et al., 2000. Injecting Equipment Exchange Schemes: Final Report, University of 14 “Prevention of the Spread of HIV/STDs,” a proposal submitted to London, Goldsmiths College, Monitoring Research Group, IHRD by Nikolaev Charitable Foundation (Blagodijnist), Ukraine, London, November 1998. 1999. 29 Watters, J.K., Estilo, M.J., Clark, G.L., et al., “Syringe and needle 15 Proposal submitted to IHRD by AIDS Prevention Center, Latvia, exchange as HIV/AIDS prevention for injecting drug users,” 2000. Journal of the American Medical Association, 271: 115-20, 1994. 16 The Global Impact of Drug-Resistant Tuberculosis, Program in 30 WHO International Collaborative Group, Multi-city Study on Drug Infectious Disease and Social Change, Harvard Medical School, Injecting and Risk of HIV Infection, World Health Organization, Boston, MA; 1999. Geneva, 1994. 17 Zuger, Abigail, “Russia Has Few Weapons As Infectious Diseases 31 See, among others: Novick,, D.M., Joseph, H., Croxson, T.S., Surge,” The New York Times, 5 December 2000. et al., “Absence of antibody to Human Immunodeficiency Virus 18 Joint UNAIDS/WHO Press Release, WHO14, 22 March 2001. in long-term, socially rehabilitated methadone maintenance 19 Ibid. patients.” Archives of Internal Medicine, 1990;150:97-99. Ball, 20 Dehne, K.L., Kobyshcha, Y., The HIV Epidemic in Central and J.C., Ross, A., The Effectiveness of Methadone Maintenance Treatment, Eastern Europe: Update 2000, 29 November 2000. New York: Springer-Verlag; 1991;166-170. Ward, J., Mattick, R., 21 Ibid. Hall, W. Key Issues in Methadone Maintenance Treatment, New 22 Ibid. South Wales, Australia: New South Wales University Press; 23 Ibid. 1992:56. 24 Arkadiusz Majszyk, quoted in the Scotsman, 1 December 2000. 32 See, among others: Hubbard, R.L., Rachel, J.V., Craddock, S.G., 25 Grund, J.-P., Ofner, P. J., Verbraeck, H. T., “An Exploration of Cavanaugh, E.R., “Treatment Outcome Prospective Study (TOPS): Drug Use and HIV Risks Among the Roma of Central and Eastern Client characteristics and behaviors before, during, and after Europe,” research report, DV8 Research, Training and treatment,” In: Tims, F.M., Ludford, J.P., eds., Drug Abuse Development, Rotterdam, The Netherlands, 2000. Treatment Evaluation: Strategies, Progress, and Prospects, NIDA 26 Burrows, Dave, Starting and Managing Needle and Syringe Programs: Research Monograph 51. Rockville, MD: US Department of Health A Guide for Central and Eastern Europe and the Newly Independent and Human Services; 1984:42-68. Newman, R.G., Peyser, N., States of the Former Soviet Union, IHRD, 1999. “Methadone treatment: Experiment and experience,” Journal of 27 See, among others: U.S. Conference of Mayors, Needle Exchange: Psychoactive Drugs 1991;23:115-121.
72 IHRD The global HIV epidemic is spreading through the countries of Eastern Europe and the former Soviet Union in tandem with a steep rise in injection drug use. In parts of the region, the HIV infection rate is increasing faster than anywhere else in the world. Despite such alarming statistics, injecting drug users (IDUs), who are among the most at risk of HIV infection, are not receiving the attention and care they deserve. . . . (continued on page 9)
IHRD INTERNATIONAL HARM REDUCTION DEVELOPMENT
OPEN SOCIETY INSTITUTE